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Wells GA, Hsieh SC, Peterson J, Zheng C, Kelly SE, Shea B, Tugwell P. Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev 2024; 4:CD003376. [PMID: 38591743 PMCID: PMC11003221 DOI: 10.1002/14651858.cd003376.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
BACKGROUND Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Etidronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts - bone cells that break down bone tissue. This is an update of a Cochrane review first published in 2008. For clinical relevance, we investigated etidronate's effects on postmenopausal women stratified by fracture risk (low versus high). OBJECTIVES To assess the benefits and harms of intermittent/cyclic etidronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively. SEARCH METHODS We searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE, Embase, two clinical trial registers, the websites of drug approval agencies, and the bibliographies of relevant systematic reviews. We identified eligible trials published between 1966 and February 2023. SELECTION CRITERIA We included randomized controlled trials that assessed the benefits and harms of etidronate in the prevention of fractures for postmenopausal women. Women in the experimental arms must have received at least one year of etidronate, with or without other anti-osteoporotic drugs and concurrent calcium/vitamin D. Eligible comparators were placebo (i.e. no treatment; or calcium, vitamin D, or both) or another anti-osteoporotic drug. Major outcomes were clinical vertebral, non-vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events. We classified a study as secondary prevention if its population fulfilled one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T-score (≤ -2.5), or aged 75 years or older. If none of these criteria were met, we considered the study to be primary prevention. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The review has three main comparisons: (1) etidronate 400 mg/day versus placebo; (2) etidronate 200 mg/day versus placebo; (3) etidronate at any dosage versus another anti-osteoporotic agent. We stratified the analyses for each comparison into primary and secondary prevention studies. For major outcomes in the placebo-controlled studies of etidronate 400 mg/day, we followed our original review by defining a greater than 15% relative change as clinically important. For all outcomes of interest, we extracted outcome measurements at the longest time point in the study. MAIN RESULTS Thirty studies met the review's eligibility criteria. Of these, 26 studies, with a total of 2770 women, reported data that we could extract and quantitatively synthesize. There were nine primary and 17 secondary prevention studies. We had concerns about at least one risk of bias domain in each study. None of the studies described appropriate methods for allocation concealment, although 27% described adequate methods of random sequence generation. We judged that only 8% of the studies avoided performance bias, and provided adequate descriptions of appropriate blinding methods. One-quarter of studies that reported efficacy outcomes were at high risk of attrition bias, whilst 23% of studies reporting safety outcomes were at high risk in this domain. The 30 included studies compared (1) etidronate 400 mg/day to placebo (13 studies: nine primary and four secondary prevention); (2) etidronate 200 mg/day to placebo (three studies, all secondary prevention); or (3) etidronate (both dosing regimens) to another anti-osteoporotic agent (14 studies: one primary and 13 secondary prevention). We discuss only the etidronate 400 mg/day versus placebo comparison here. For primary prevention, we collected moderate- to very low-certainty evidence from nine studies (one to four years in length) including 740 postmenopausal women at lower risk of fractures. Compared to placebo, etidronate 400 mg/day probably results in little to no difference in non-vertebral fractures (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.20 to 1.61); absolute risk reduction (ARR) 4.8% fewer, 95% CI 8.9% fewer to 6.1% more) and serious adverse events (RR 0.90, 95% CI 0.52 to 1.54; ARR 1.1% fewer, 95% CI 4.9% fewer to 5.3% more), based on moderate-certainty evidence. Etidronate 400 mg/day may result in little to no difference in clinical vertebral fractures (RR 3.03, 95% CI 0.32 to 28.44; ARR 0.02% more, 95% CI 0% fewer to 0% more) and withdrawals due to adverse events (RR 1.41, 95% CI 0.81 to 2.47; ARR 2.3% more, 95% CI 1.1% fewer to 8.4% more), based on low-certainty evidence. We do not know the effect of etidronate on hip fractures because the evidence is very uncertain (RR not estimable based on very low-certainty evidence). Wrist fractures were not reported in the included studies. For secondary prevention, four studies (two to four years in length) including 667 postmenopausal women at higher risk of fractures provided the evidence. Compared to placebo, etidronate 400 mg/day may make little or no difference to non-vertebral fractures (RR 1.07, 95% CI 0.72 to 1.58; ARR 0.9% more, 95% CI 3.8% fewer to 8.1% more), based on low-certainty evidence. The evidence is very uncertain about etidronate's effects on hip fractures (RR 0.93, 95% CI 0.17 to 5.19; ARR 0.0% fewer, 95% CI 1.2% fewer to 6.3% more), wrist fractures (RR 0.90, 95% CI 0.13 to 6.04; ARR 0.0% fewer, 95% CI 2.5% fewer to 15.9% more), withdrawals due to adverse events (RR 1.09, 95% CI 0.54 to 2.18; ARR 0.4% more, 95% CI 1.9% fewer to 4.9% more), and serious adverse events (RR not estimable), compared to placebo. Clinical vertebral fractures were not reported in the included studies. AUTHORS' CONCLUSIONS This update echoes the key findings of our previous review that etidronate probably makes or may make little to no difference to vertebral and non-vertebral fractures for both primary and secondary prevention.
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Affiliation(s)
- George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Shu-Ching Hsieh
- Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Canada
| | - Joan Peterson
- Clinical Epidemiology Unit, Ottawa Civic Hospital / Loeb Research Institute, Ottawa, Canada
| | - Carine Zheng
- University of Ottawa Heart Institute, Ottawa, Canada
| | - Shannon E Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
| | - Beverley Shea
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | - Peter Tugwell
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
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Tsai WH, Sung FC, Muo CH, Tsai MC, Wu SI. Antiosteoporosis medications and cardiovascular disease: a population-based nationwide nested case-control study. Front Pharmacol 2023; 14:1220174. [PMID: 37881187 PMCID: PMC10595014 DOI: 10.3389/fphar.2023.1220174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/20/2023] [Indexed: 10/27/2023] Open
Abstract
Purpose: Patients with osteoporosis are at an increased risk of cardiovascular disease (CVD). Several antiosteoporosis medications have been demonstrated with the benefit of preventing osteoporosis. Our aim is to assess the CVD risks associated with antiosteoporosis medications using the National Health Insurance Research Database in Taiwan between 2000 and 2016. Methods: Among 41,102 patients of 40+ years old with newly diagnosed osteoporosis, 69.1% (N = 28,387) of patients were included in the user cohort of antiosteoporosis medicines, of whom 13, 472 developed CVD by the end of 2016, while 14,915 did not. Using the nested case-control analysis in the user cohort (88.0% women and 77.4% elderly), we applied conditional logistic regression to estimate odds ratios (ORs) of eight types of CVD for the users of denosumab, bisphosphonate, teriparatide, and hormone replacement therapy (HRT). Results: The adjusted ORs of overall CVDs were 0.13 (95% CI: 0.12-0.15) for denosumab users, 0.52 (95% CI: 0.45-0.61) for teriparatide users, and 0.80 (95% CI: 0.76-0.85) for bisphosphonate users. The HRT users were at higher odds of coronary artery and peripheral artery diseases, heart failure, pulmonary embolism, and deep vein thrombosis. Conclusion: Denosumab, teriparatide, and bisphosphonate may have more protective effects against CVD than hormone therapy. Physicians may take subsequent cardiovascular risks into account when choosing an adequate antiosteoporosis medication for patients with osteoporosis.
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Affiliation(s)
- Wen-Hsuan Tsai
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Fung-Chang Sung
- Management Office for Health Data, Clinical Trial Research Center, China Medical University Hospital, Taichung, Taiwan
- Department of Health Services Administration, China Medical University College of Public Health, Taichung, Taiwan
- Department of Food Nutrition and Health Biotechnology, Asia University, Taichung, Taiwan
| | - Chih-Hsin Muo
- Management Office for Health Data, Clinical Trial Research Center, China Medical University Hospital, Taichung, Taiwan
| | - Ming-Chieh Tsai
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shu-I. Wu
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
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Gazoni FM, Civile VT, Atallah ÁN, Santos FC, Trevisani VFM. Intravenous zoledronate for postmenopausal women with osteopenia and osteoporosis: a systematic review and metanalysis. SAO PAULO MED J 2023; 141:e2022480. [PMID: 37255065 DOI: 10.1590/1516-3180.2022.0480.r1.27032023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 03/27/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Osteoporosis compromises bone strength and increases the risk of fractures. Zoledronate prevents loss of bone mass and reduces the risk of fractures. OBJECTIVES To determine the efficacy and safety of zoledronate in postmenopausal women with osteopenia and osteoporosis. DESIGN AND SETTINGS A systematic review and meta-analysis was conducted within the evidence-based health program at the Universidade Federal de São Paulo. METHODS An electronic search of the CENTRAL, MEDLINE, Embase, and LILACS databases was performed until February 2022. Randomized controlled trials comparing zoledronate with placebo or other bisphosphonates were included. Standard methodological procedures were performed according to the Cochrane Handbook and the certainty of evidence for the Grading of Recommendations Assessment, Development, and Evaluation Working Group. Two authors assessed the risk of bias and extracted data on fractures, adverse events, bone turnover markers (BTM), and bone mineral density (BMD). RESULTS Twelve trials from 6,652 records were included: nine compared zoledronate with placebo, two trials compared zoledronate with alendronate, and one trial compared zoledronate with ibandronate. Zoledronate reduced the incidence of fractures in osteoporotic [three years: morphometric vertebral fractures (relative risk, RR = 0.30 (95% confidence interval, CI: 0.24-0.38))] and osteopenic women [six years: morphometric vertebral fractures (RR = 0.39 (95%CI: 0.25-0.61))], increased incidence of post-dose symptoms [RR = 2.56 (95%CI: 1.80-3.65)], but not serious adverse events [RR = 0.97 (95%CI: 0.91-1.04)]. Zoledronate reduced BTM and increased BMD in osteoporotic and osteopenic women. CONCLUSION This review supports the efficacy and safety of zoledronate in postmenopausal women with osteopenia for six years and osteoporosis for three years. PROSPERO REGISTRATION NUMBER CRD42022309708, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=309708.
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Affiliation(s)
- Fernanda Martins Gazoni
- MD. Doctoral Student, Evidence-Based Health Program, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil; Geriatrician, Discipline of Geriatrics and Gerontology, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil
| | - Vinicius Tassoni Civile
- MD, PhD. Physiotherapist, Evidence-Based Health Program, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil; Assistant Professor, Physiotherapy Course, Universidade Paulista (UNIP), São Paulo (SP), Brazil; Volunteer Researcher, Cochrane Brazil, São Paulo (SP), Brazil
| | - Álvaro Nagib Atallah
- MD, MSc, PhD. Nephrologist and Full Professor, Discipline of Emergency and Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil; Director, Cochrane Brazil, São Paulo (SP), Brazil
| | - Fânia Cristina Santos
- MD, MSc, PhD. Geriatrician and Assistant Professor, Discipline of Geriatrics and Gerontology, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil
| | - Virginia Fernandes Moça Trevisani
- MD, MSc, PhD. Rheumatologist and Assistant Professor, Discipline of Emergency and Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil; Rheumatologist and Full Professor, Discipline of Rheumatology, Universidade Santo Amaro (UNISA), São Paulo (SP), Brazil
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Rodríguez AJ, Nerlekar N, Ebeling PR. Cardiac adverse events in bisphosphonate and teriparatide users: An international pharmacovigilance study. Bone 2023; 168:116647. [PMID: 36543300 DOI: 10.1016/j.bone.2022.116647] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 12/08/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cardiovascular effects of osteoporosis medications have recently been highlighted. Although oral and intravenous bisphosphonates are assumed to have similar cardiovascular safety, few head-to-head comparisons exist. The cardiovascular safety of teriparatide is unknown. Aim We conducted a pharmacovigilance safety study of cardiac events using real-life adverse event reports from alendronate, zoledronic acid and teriparatide users. METHODS Adverse drug reactions were obtained from Vigibase, a WHO database of individual case safety reports (ICSRs) from 130 countries (1967-2020). ISCRs for atrial fibrillation (AF), angina pectoris, arteriosclerosis coronary artery (ACA), cardiac arrhythmias, coronary artery disease (CAD), thromboembolic events (TE), ischaemic heart disease (IHD), torsade de pointes/QT prolongation (TDP) associated with alendronate, zoledronic acid and teriparatide use were extracted. Data were included in a disproportionality analysis where the lower end of the 95 % credibility interval for the information component (IC025), showing a statistical association when >0. Head-to-head comparisons of ISCRs were estimated by age-adjusted odds ratios and 95 % confidence intervals. RESULTS 465 episodes of angina, 287 ACA, 13,385 arrhythmias, 792 CAD, 6743 TE, 3264 IHD, 1037 myocardial infarcts, and 3714 TDP events were recorded across 50,365 alendronate, 52,436 zoledronic acid and 137,629 teriparatide users. There was a significant association between alendronate and zoledronate with all outcomes except MI. Teriparatide use was associated with AF, arrythmias and angina only. In head-to-head comparisons, teriparatide use was associated with fewer ACA and CAD events than alendronate and fewer ACA than zoledronic acid. DISCUSSION Osteoporosis medication use is associated with adverse cardiac events, except for MI, and these appear to be more common with oral and intravenous bisphosphonates than teriparatide. Our data do not support differential effects of oral and intravenous bisphosphonates on cardiac events. Mechanisms whereby teriparatide may be cardio-protective warrant further investigation.
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Affiliation(s)
- Alexander J Rodríguez
- Bone and Muscle Health Research Group, Department of Medicine, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia; Disorders of Mineralisation Research Group, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia.
| | - Nitesh Nerlekar
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia; Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Peter R Ebeling
- Bone and Muscle Health Research Group, Department of Medicine, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia; Department of Medicine, Monash University, Clayton, Victoria, Australia; Department of Endocrinology, Monash Health, Clayton, Australia
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Frost K. Onco-Nephrology in the Critical Care Setting. Crit Care Nurs Clin North Am 2022; 34:453-466. [DOI: 10.1016/j.cnc.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Pineda‐Moncusí M, El‐Hussein L, Delmestri A, Cooper C, Moayyeri A, Libanati C, Toth E, Prieto‐Alhambra D, Khalid S. 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. J Bone Miner Res 2022; 37:1986-1996. [PMID: 35818312 PMCID: PMC9826104 DOI: 10.1002/jbmr.4648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/31/2022] [Accepted: 07/07/2022] [Indexed: 01/11/2023]
Abstract
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).
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Affiliation(s)
- Marta Pineda‐Moncusí
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic CentreUniversity of OxfordOxfordUK
| | - Leena El‐Hussein
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic CentreUniversity of OxfordOxfordUK
| | - Antonella Delmestri
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic CentreUniversity of OxfordOxfordUK
| | - Cyrus Cooper
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic CentreUniversity of OxfordOxfordUK
- MRC Lifecourse Epidemiology UnitUniversity of Southampton, Southampton General HospitalSouthamptonUK
| | | | | | | | - Daniel Prieto‐Alhambra
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic CentreUniversity of OxfordOxfordUK
- MRC Lifecourse Epidemiology UnitUniversity of Southampton, Southampton General HospitalSouthamptonUK
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gorina (IDIAPJ Gol)CIBERFESBarcelonaSpain
- Universitat Autònoma de BarcelonaBellaterra (Cerdanyola del Vallès)Cerdanyola del VallèsSpain
| | - Sara Khalid
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic CentreUniversity of OxfordOxfordUK
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Wells GA, Hsieh SC, Zheng C, Peterson J, Tugwell P, Liu W. Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev 2022; 5:CD004523. [PMID: 35502787 PMCID: PMC9062986 DOI: 10.1002/14651858.cd004523.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Osteoporosis is an abnormal reduction in bone mass and bone deterioration leading to increased fracture risk. Risedronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts. This is an update of a Cochrane Review that was originally published in 2003. OBJECTIVES We assessed the benefits and harms of risedronate in the primary and secondary prevention of osteoporotic fractures for postmenopausal women at lower and higher risk for fractures, respectively. SEARCH METHODS With broader and updated strategies, we searched the Cochrane Central Register of Control Trials (CENTRAL), MEDLINE and Embase. A grey literature search, including the online databases ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), and drug approval agencies, as well as bibliography checks of relevant systematic reviews was also performed. Eligible trials published between 1966 to 24 March 2021 were identified. SELECTION CRITERIA We included randomised controlled trials that assessed the benefits and harms of risedronate in the prevention of fractures for postmenopausal women. Participants must have received at least one year of risedronate, placebo or other anti-osteoporotic drugs, with or without concurrent calcium/vitamin D. Major outcomes were clinical vertebral, non-vertebral, hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. In the interest of clinical relevance and applicability, we classified a study as secondary prevention if its population fulfilled more than one of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, low bone mineral density (BMD)T score ≤ -2.5, and age ≥ 75 years old. If none of these criteria was met, the study was considered to be primary prevention. DATA COLLECTION AND ANALYSIS We used standard methodology expected by Cochrane. We pooled the relative risk (RR) of fractures using a fixed-effect model based on the expectation that the clinical and methodological characteristics of the respective primary and secondary prevention studies would be homogeneous, and the experience from the previous review suggesting that there would be a small number of studies. The base case included the data available for the longest treatment period in each placebo-controlled trial and a >15% relative change was considered clinically important. The main findings of the review were presented in summary of findings tables, using the GRADE approach. In addition, we looked at benefit and harm comparisons between different dosage regimens for risedronate and between risedronate and other anti-osteoporotic drugs. MAIN RESULTS Forty-three trials fulfilled the eligibility criteria, among which 33 studies (27,348 participants) reported data that could be extracted and quantitatively synthesized. We had concerns about particular domains of risk of bias in each trial. Selection bias was the most frequent concern, with only 24% of the studies describing appropriate methods for both sequence generation and allocation concealment. Fifty per cent and 39% of the studies reporting benefit and harm outcomes, respectively, were subject to high risk. None of the studies included in the quantitative syntheses were judged to be at low risk of bias in all seven domains. The results described below pertain to the comparisons for daily risedronate 5 mg versus placebo which reported major outcomes. Other comparisons are described in the full text. For primary prevention, low- to very low-certainty evidence was collected from four studies (one to two years in length) including 989 postmenopausal women at lower risk of fractures. Risedronate 5 mg/day may make little or no difference to wrist fractures [RR 0.48 ( 95% CI 0.03 to 7.50; two studies, 243 participants); absolute risk reduction (ARR) 0.6% fewer (95% CI 1% fewer to 7% more)] and withdrawals due to adverse events [RR 0.67 (95% CI 0.38 to 1.18; three studies, 748 participants); ARR 2% fewer (95% CI 5% fewer to 1% more)], based on low-certainty evidence. However, its preventive effects on non-vertebral fractures and serious adverse events are not known due to the very low-certainty evidence. There were zero clinical vertebral and hip fractures reported therefore the effects of risedronate for these outcomes are not estimable. For secondary prevention, nine studies (one to three years in length) including 14,354 postmenopausal women at higher risk of fractures provided evidence. Risedronate 5 mg/day probably prevents non-vertebral fractures [RR 0.80 (95% CI 0.72 to 0.90; six studies, 12,173 participants); RRR 20% (95% CI 10% to 28%) and ARR 2% fewer (95% CI 1% fewer to 3% fewer), moderate certainty], and may reduce hip fractures [RR 0.73 (95% CI 0.56 to 0.94); RRR 27% (95% CI 6% to 44%) and ARR 1% fewer (95% CI 0.2% fewer to 1% fewer), low certainty]. Both of these effects are probably clinically important. However, risedronate's effects are not known for wrist fractures [RR 0.64 (95% CI 0.33 to 1.24); three studies,1746 participants); ARR 1% fewer (95% CI 2% fewer to 1% more), very-low certainty] and not estimable for clinical vertebral fractures due to zero events reported (low certainty). Risedronate results in little to no difference in withdrawals due to adverse events [RR 0.98 (95% CI 0.90 to 1.07; eight studies, 9529 participants); ARR 0.3% fewer (95% CI 2% fewer to 1% more); 16.9% in risedronate versus 17.2% in control, high certainty] and probably results in little to no difference in serious adverse events [RR 1.00 (95% CI 0.94 to 1.07; six studies, 9435 participants); ARR 0% fewer (95% CI 2% fewer to 2% more; 29.2% in both groups, moderate certainty). AUTHORS' CONCLUSIONS This update recaps the key findings from our previous review that, for secondary prevention, risedronate 5 mg/day probably prevents non-vertebral fracture, and may reduce the risk of hip fractures. We are uncertain on whether risedronate 5mg/day reduces clinical vertebral and wrist fractures. Compared to placebo, risedronate probably does not increase the risk of serious adverse events. For primary prevention, the benefit and harms of risedronate were supported by limited evidence with high uncertainty.
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Affiliation(s)
- George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Shu-Ching Hsieh
- Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Canada
| | - Carine Zheng
- University of Ottawa Heart Institute, Ottawa, Canada
- Statistics Canada, Ottawa, Canada
| | - Joan Peterson
- Clinical Epidemiology Unit, Ottawa Civic Hospital / Loeb Research Institute, Ottawa, Canada
| | - Peter Tugwell
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- WHO Collaborating Centre for Knowledge Translation and Health Technology Assessment in Health Equity, Bruyère Research Institute, Ottawa, Canada
| | - Wenfei Liu
- Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Canada
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Park JH, Ko HJ. The Association between Treatment with Bisphosphonates and the Risk of Atrial Fibrillation: A Meta-Analysis of Observational Studies. Korean J Fam Med 2022; 43:69-76. [PMID: 35130642 PMCID: PMC8820972 DOI: 10.4082/kjfm.21.0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/14/2021] [Indexed: 11/03/2022] Open
Abstract
Background: Osteoporosis is one of the most common diseases of the skeletal system, particularly occurring in older adults. Bisphosphonates are frequently used to treat osteoporosis and prevent bone fractures. Studies evaluating the association between treatment with bisphosphonate and the risk of atrial fibrillation have reported conflicting results. This meta-analysis of observational studies was performed to assess this association.Methods: Databases were searched to find relevant observational studies, and the identified articles were selected according to the selection criteria. Sensitivity and subgroup analysis based on various confounding factors were performed. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of atrial fibrillation were estimated using a random-effects model.Results: We selected 12 studies, including four case-control and eight cohort studies, for the meta-analysis. Assessment of the estimated effect size yielded an OR of 1.171 (95% CI, 1.011–1.356; P=0.035), with substantial heterogeneity (I 2 =84.74%, P<0.001). When the studies were excluded one-after-another, the pooled OR remained unchanged in only six studies. In addition, subgroup analyses found that treatment with bisphosphonates was positively associated with the risk of atrial fibrillation in studies performed in Western countries (OR, 1.263; 95% CI, 1.092–1.462) and lower-quality studies (OR, 1.214; 95% CI, 1.035–1.423). No publication bias was observed.Conclusion: This meta-analysis showed that treatment with bisphosphonates may be associated with an increased risk of atrial fibrillation. Therefore, bisphosphonates should be carefully prescribed to patients at a high risk of atrial fibrillation.
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Affiliation(s)
- Ji-Hyun Park
- Department of Family Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Hae-Jin Ko
- Department of Family Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
- Corresponding Author: Hae-Jin Ko Tel: +82-53-200-6578, Fax: +82-53-200-5480, E-mail:
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9
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Rodríguez AJ, Abrahamsen B. Cardiovascular Safety of Antifracture Medications in Patients With Osteoporosis: A Narrative Review of Evidence From Randomized Studies. JBMR Plus 2021; 5:e10522. [PMID: 34258509 PMCID: PMC8260817 DOI: 10.1002/jbm4.10522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/02/2021] [Indexed: 01/10/2023] Open
Abstract
Osteoporosis and cardiovascular (CV) disease share common risk factors and pathophysiology. Low bone mineral density (BMD) and fractures appear to increase the risk for multiple CV diseases. Equally, prevalent CV disease appears to predispose to bone loss and increase fracture rates. This relationship has naturally provoked the hypothesis that stopping bone loss may result in some CV benefit. Secondary analyses of safety and adverse event data from many randomized controlled trials (RCTs) have attempted to clarify this putative association. Recently, the discontinuation of odanacatib (anti-cathepsin K monoclonal antibody) over stroke concerns and the imbalance in ischemic events in romosozumab-treated (anti-sclerostin monoclonal antibody) women compared to bisphosphonate-treated women, has provided further justification to better characterize potential CV benefits and harms of osteoporosis medications. This review delves into the seminal, and other major RCTs of osteoporosis medications and, using both published data and additional information provided on trial registration pages, examines the evidence for CV safety and harms of these medications. Accepted and emerging "off-target" effects are explored for validity, biological plausibility, and clinical importance. A brief research agenda is provided to stimulate the next wave of clinical development and CV understanding of osteoporosis medications. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Alexander J Rodríguez
- Bone and Muscle Health Research Group, Department of Medicine, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences Monash University, Monash Medical Centre Clayton Victoria Australia.,Disorders of Mineralisation Research Group, School of Medical and Health Sciences Edith Cowan University Joondalup Western Australia Australia
| | - Bo Abrahamsen
- Department of Medicine Holbæk Hospital Holbæk Denmark.,Odense Patient Data Explorative Network (OPEN) University of Southern Denmark Odense Denmark
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10
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Pan X, Li X. Bisphosphonates on mortality and cardiovascular risk. J Formos Med Assoc 2021; 120:2044-2045. [PMID: 33994060 DOI: 10.1016/j.jfma.2021.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 04/27/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Xiaoping Pan
- Department of Pharmacy, YiWu Central Hospital, Zhejiang 322000, China
| | - Xiaofei Li
- Department of Infectious Diseases, YiWu Central Hospital, Zhejiang, China.
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11
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Lin Y, Villacanas MG, Zou H, Liu H, Carcedo IG, Wu Y, Sun B, Wu X, Prasadam I, Monteiro MJ, Li L, Xu ZP, Gu W. Calcium-bisphosphonate Nanoparticle Platform as a Prolonged Nanodrug and Bone-Targeted Delivery System for Bone Diseases and Cancers. ACS APPLIED BIO MATERIALS 2021; 4:2490-2501. [DOI: 10.1021/acsabm.0c01455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yanling Lin
- Australian Institute of Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Maria G. Villacanas
- Australian Institute of Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Hong Zou
- Australian Institute of Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD 4072, Australia
- Department of Pathology/Key Laboratories for Xinjiang Endemic and Ethnic Diseases, Shihezi University School of Medicine, Shihezi, Xinjiang 832002, China
| | - Hangrui Liu
- Australian Institute of Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Ines G. Carcedo
- Australian Institute of Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Yilun Wu
- Australian Institute of Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Bing Sun
- Australian Institute of Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Xiaoxin Wu
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4000, Australia
| | - Indira Prasadam
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4000, Australia
| | - Michael J. Monteiro
- Australian Institute of Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Li Li
- Australian Institute of Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Zhi Ping Xu
- Australian Institute of Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Wenyi Gu
- Australian Institute of Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD 4072, Australia
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12
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Cellini M, Rotondi M, Tanda ML, Piantanida E, Chiovato L, Beck-Peccoz P, Lania A, Mazziotti G. Skeletal health in patients with differentiated thyroid carcinoma. J Endocrinol Invest 2021; 44:431-442. [PMID: 32696339 DOI: 10.1007/s40618-020-01359-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/09/2020] [Indexed: 02/06/2023]
Abstract
Osteoporosis and fractures are important comorbidities in patients with differentiated thyroid cancer (DTC), with potential negative impact on quality of life and survival. The main determinant of skeletal fragility in DTC is the thyrotropin (TSH)-suppressive therapy, which is commonly recommended to prevent disease's recurrence, especially in patients with structural incomplete response after thyroid surgery and radio-iodine therapy. TSH-suppressive therapy can stimulate bone resorption with consequent bone loss, deterioration of bone microstructure and high risk of fragility fractures. The skeletal effects of TSH-suppressive therapy may be amplified when thyroid cancer cells localize to the skeleton inducing alterations in bone remodelling, impairment of bone structure and further increase in risk of fractures. The management of skeletal fragility in DTC may be challenging, since prediction of fractures is a matter of uncertainty and data on effectiveness and safety of bone-active agents in this clinical setting are still scanty. This review deals with pathophysiological, clinical and therapeutic aspects of skeletal fragility of patients with DTC.
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Affiliation(s)
- M Cellini
- Endocrinology, Diabetology and Andrology Unit, Humanitas Clinical and Research Center, IRCCS, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - M Rotondi
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, 27100, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100, Pavia, Italy
| | - M L Tanda
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST Dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - E Piantanida
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST Dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - L Chiovato
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, 27100, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100, Pavia, Italy
| | - P Beck-Peccoz
- University of Milan, Via Pietro Custodi 16, 20136, Milan, Italy
| | - Andrea Lania
- Endocrinology, Diabetology and Andrology Unit, Humanitas Clinical and Research Center, IRCCS, via Manzoni 56, 20089, Rozzano, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20090, Milan, Italy.
| | - G Mazziotti
- Endocrinology, Diabetology and Andrology Unit, Humanitas Clinical and Research Center, IRCCS, via Manzoni 56, 20089, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4 Pieve Emanuele, 20090, Milan, Italy
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13
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The impact of bisphosphonates on mortality and cardiovascular risk among osteoporosis patients after cardiovascular disease. J Formos Med Assoc 2020; 120:1957-1966. [PMID: 33358773 DOI: 10.1016/j.jfma.2020.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/11/2020] [Accepted: 12/10/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND/PURPOSE Bisphosphonates (BPs) impact on the survival and cardiovascular safety of osteoporosis patients after acute coronary syndrome (ACS) or acute ischemic stroke (AIS) was evaluated. METHODS A nationwide epidemiological study was conducted using the Taiwan National Health Insurance Research Database from 2000 to 2010. From the 1456 osteoporosis patients with previous ACS or AIS, mortality and cardiovascular safety was compared between 464 patients who used BPs and 464 patients who did not. Primary outcomes included all-cause mortality, and major adverse cardiovascular events. RESULTS The BPs group had a lower risk of all-cause mortality than the control group after the 8-year follow-up (HR, 0.64; 95% CI, 0.46-0.88; P = 0.006). The risks of myocardial infarction, ischemic stroke, cardiovascular death, hospitalization for heart failure or other causes of mortality were similar across groups. However, there was a higher risk of hospitalization for atrial fibrillation in the BPs group than the control group (HR, 1.76; 95% CI, 1.26-2.46; P = 0.001). CONCLUSION Among osteoporosis patients after ACS or AIS, BPs use was associated with a reduced risk of all-cause mortality. However, patients with previous cardiovascular disease who received BP treatment should be careful about the risk of atrial fibrillation.
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14
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Abstract
Thyroid hormones stimulate bone turnover in adults by increasing osteoclastic bone resorption. TSH suppressive therapy is usually applied in patients with differentiated thyroid cancer (DTC) to improve the disease outcome. Over the last decades several authors have closely monitored the potential harm suffered by the skeletal system. Several studies and meta-analyses have shown that chronic TSH suppressive therapy is safe in premenopausal women and men. Conversely, in postmenopausal women TSH suppressive therapy is associated with a decrease of bone mineral density, deterioration of bone architecture (quantitative CT, QCT; trabecular bone score, TBS), and, possibly, an increased risk of fractures. The TSH receptor is expressed in bone cells and the results of experimental studies in TSH receptor knockout mice and humans on whether low TSH levels, as opposed to solely high thyroid hormone levels, might contribute to bone loss in endogenous or exogenous thyrotoxicosis remain controversial. Recent guidelines on the use of TSH suppressive therapy in patients with DTC give value not only to its benefit on the outcome of the disease, but also to the risks associated with exogenous thyrotoxicosis, namely menopause, osteopenia or osteoporosis, age >60 years, and history of atrial fibrillation. Bone health (BMD and/or preferably TBS) should be evaluated in postmenopausal women under chronic TSH suppressive therapy or in those patients planning to be treated for several years. Antiresorptive therapy could also be considered in selected cases (increased risk of fracture or significant decline of BMD/TBS during therapy) to prevent bone loss.
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Affiliation(s)
- Alessandro Brancatella
- Endocrine Unit 1, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudio Marcocci
- Endocrine Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Correspondence should be addressed to C Marcocci:
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15
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Sanchez-Rodriguez D, Bergmann P, Body JJ, Cavalier E, Gielen E, Goemaere S, Lapauw B, Laurent MR, Rozenberg S, Honvo G, Beaudart C, Bruyère O. The Belgian Bone Club 2020 guidelines for the management of osteoporosis in postmenopausal women. Maturitas 2020; 139:69-89. [PMID: 32747044 DOI: 10.1016/j.maturitas.2020.05.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/06/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To provide updated evidence-based guidelines for the management of osteoporosis in postmenopausal women in Belgium. METHODS The Belgian Bone Club (BBC) gathered a guideline developer group. Nine "Population, Intervention, Comparator, Outcome" (PICO) questions covering screening, diagnosis, non-pharmacological and pharmacological treatments, and monitoring were formulated. A systematic search of MEDLINE, the Cochrane Database of Systematic Reviews, and Scopus was performed to find network meta-analyses, meta-analyses, systematic reviews, guidelines, and recommendations from scientific societies published in the last 10 years. Manual searches were also performed. Summaries of evidence were provided, and recommendations were further validated by the BBC board members and other national scientific societies' experts. RESULTS Of the 3840 references in the search, 333 full texts were assessed for eligibility, and 129 met the inclusion criteria. Osteoporosis screening using clinical risk factors should be considered. Patients with a recent (<2 years) major osteoporotic fracture were considered at very high and imminent risk of future fracture. The combination of bone mineral density measured by dual-energy X-ray absorptiometry and 10-year fracture risk was used to categorize patients as low or high risk. Patient education, the combination of weight-bearing and resistance training, and optimal calcium intake and vitamin D status were recommended. Antiresorptive and anabolic osteoporosis treatment should be considered for patients at high and very high fracture risk, respectively. Follow-up should focus on compliance, and patient-tailored monitoring should be considered. CONCLUSION BBC guidelines and 25 guideline recommendations bridge the gap between research and clinical practice for the screening, diagnosis, and management of osteoporosis.
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Affiliation(s)
- D Sanchez-Rodriguez
- WHO Collaborating Center for Public Health aspects of musculo-skeletal health and ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium; Geriatrics Department, Rehabilitation Research Group, Hospital del Mar Medical Research Institute (IMIM), Universitat Pompeu Fabra, Barcelona, Spain.
| | - P Bergmann
- Department of Radioisotopes, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - J J Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - E Cavalier
- Department of Clinical Chemistry, UnilabLg, University of Liège, CHU de Liège, Liège, Belgium
| | - E Gielen
- Gerontology and Geriatrics Section, Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), KU Leuven, University Hospitals, Leuven, Belgium
| | - S Goemaere
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - B Lapauw
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - M R Laurent
- Geriatrics Department, Imelda Hospital, Bonheiden, Belgium
| | - S Rozenberg
- Department of Gynaecology-Obstetrics, Université Libre de Bruxelles, Brussels, Belgium
| | - G Honvo
- WHO Collaborating Center for Public Health aspects of musculo-skeletal health and ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - C Beaudart
- WHO Collaborating Center for Public Health aspects of musculo-skeletal health and ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - O Bruyère
- WHO Collaborating Center for Public Health aspects of musculo-skeletal health and ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
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16
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Casula M, Olmastroni E, Galimberti F, Tragni E, Corrao G, Scotti L, Catapano AL. Association between the cumulative exposure to bisphosphonates and hospitalization for atherosclerotic cardiovascular events: A population-based study. Atherosclerosis 2020; 301:1-7. [PMID: 32289617 DOI: 10.1016/j.atherosclerosis.2020.03.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND AIMS Although bisphosphonates have been suggested to protect against atherosclerotic cardiovascular (CV) events, evidence is still conflicting. We aimed at investigating the effect of bisphosphonates on hospitalizations for atherosclerotic CV events. METHODS We carried out a retrospective cohort study selecting subjects aged>40 years, incident users of bisphosphonates. Exposure to bisphosphonates was characterized based on cumulative doses (proportion of days covered, PDC). Treatment's adherence was classified as low (PDC≤40%), intermediate (PDC 41%-80%), or high (PDC>80%). A multivariate Cox model was fitted to estimate the association between cumulative time-dependent exposure to bisphosphonates and hospitalization for atherosclerotic CV events (hazard ratio [HR] and 95% confidence interval). RESULTS Among 82,704 new bisphosphonates users (females 87.0%, mean age 70.7 ± 10.6 years), 16.1% had a CV hospitalization during a mean follow-up of 6.5 + 2.6 years. Compared with individuals with PDC ≤40%, those exposed for 41-80% or more than 80% showed HRs of CV hospitalization of 0.95 [0.91-0.99] and 0.75 [0.71-0.81], respectively. In the sub-analysis by type of event, a PDC >80% was associated with a reduced incidence for both coronary and cerebrovascular events (HRs 0.75 [0.68-0.83] and 0.76 [0.70-0.83], respectively). The protective effect was confirmed in stratified analyses by sex and age classes, and in those performed at 1 and 3 years of follow-up. CONCLUSIONS Strict adherence to bisphosphonate treatment was associated with a better CV outcome. Although further studies to investigate possible mechanisms are warranted, bisphosphonates could be considered as having a potential CV benefit beyond the effect on bones.
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Affiliation(s)
- Manuela Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni (Milan), Italy.
| | - Elena Olmastroni
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Federica Galimberti
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Elena Tragni
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Giovanni Corrao
- National Centre for Healthcare Research & Pharmacoepidemiology, Milan, Italy; Laboratory of Healthcare Research & Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Lorenza Scotti
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Alberico L Catapano
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni (Milan), Italy
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17
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Bone Metabolism Impairment in Heart Transplant: Results From a Prospective Cohort Study. Transplantation 2020; 104:873-880. [DOI: 10.1097/tp.0000000000002906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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No impact of anti-Rank ligand and PTH analogs on cardiovascular risk in postmenopausal osteoporosis: a systematic literature review and meta-analysis. Arch Osteoporos 2020; 15:10. [PMID: 31897759 DOI: 10.1007/s11657-019-0672-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/14/2019] [Indexed: 02/03/2023]
Abstract
The mutual effects of drugs used in osteoporosis and cardiovascular diseases are a point of interest. A literature review and meta-analysis were conducted to address the impact of PTH analogs and anti-Rank ligand on cardiovascular events and overall mortality in individuals with idiopathic osteoporosis; these treatments do not appear to have any effect. INTRODUCTION Two meta-analyses have been conducted to explore the cardiovascular effects of bisphosphonates. There is no review for other osteoporosis treatments. A literature review and meta-analysis were conducted to address the impact of PTH analogs and anti-Rank ligand on cardiovascular events and overall mortality in individuals with idiopathic osteoporosis. METHODS A systematic review was conducted in December 2017 in the PubMed, Embase, and Cochrane databases and updated on PubMed in July 2019, selecting trials with a treatment and a control group. We also conducted a search for abstracts of the French Rheumatology Society, American College of Rheumatology, and European League Against Rheumatism's annual meetings over the past 4 years. The main endpoint was the occurrence of cardiovascular events; the secondary was mortality (all causes). RESULTS Of the 2782 reports initially found, 16 articles were used for the meta-analysis (6 for the anti-Rank ligand and 10 for the PTH analog group). After meta-analysis, there was no significant difference between the placebo group and the anti-Rank ligand group for overall mortality (p = 0.13), the combined endpoint (overall mortality, coronary artery disease, and stroke; p 0.77), and the individual risk of coronary artery disease (p 0.53), arrhythmia (p 0.95), and stroke (p 0.62). After meta-analysis, there was no significant difference between the placebo group and the PTH analogs group for overall mortality (p 0.77), the combined endpoint (p = 0.95), and the individual risk of coronary artery disease (p = 0.74), arrhythmia (p = 0.28), and stroke (p = 0.61). CONCLUSIONS The anti-Rank ligand and PTH analogs have no impact on cardiovascular risk and overall mortality in idiopathic osteoporosis. To better answer the question whether these treatments can reduce the long-term cardiovascular risk, further comparative studies with longer duration are required.
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19
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Asghar ZB, Godoy Caballero A, Pathirannehelage S, Williams J, McKay S, Grassby P, de Lusignan S, Niroshan Siriwardena A. Saving bones without risking brain-bisphosphonates and risk of stroke: matched case-control study. Osteoporos Int 2019; 30:1845-1854. [PMID: 31214750 DOI: 10.1007/s00198-019-05045-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 06/04/2019] [Indexed: 11/27/2022]
Abstract
UNLABELLED We investigated the association between bisphosphonate treatment and the risk of stroke using a large routine clinical dataset. We found no association between bisphosphonate treatment and risk of stroke, after adjusting for large number of clinical and demographic confounders. INTRODUCTION There is conflicting evidence on the link between bisphosphonates and stroke with studies variously showing increased, decreased or unchanged risk. We investigated the association between bisphosphonate treatment and the risk of stroke using a large routine clinical dataset. METHODS We used a matched nested case-control study design analysing routinely collected electronic data from patients registered at primary care practices in England participating in the Royal College of General Practitioners Research and Surveillance Centre. Cases were patients aged 18 years or over, either living or dead, recorded as having had a stroke in the period 1 January 2005 to 31 March 2016. Each case was matched to one control according to age, sex, general practice attended and calendar time. Data were analysed using Stata, version 14.2. and RStudio, version 1.1.463. Conditional logistic regression was used to determine odds ratios for stroke according to bisphosphonate treatment and duration in cases compared with controls. We adjusted for disease risk groups, cardiovascular risk factors, treatments, smoking status, alcohol consumption, ethnicity, bisphosphonate types, fracture and socioeconomic status using IMD (Index of Multiple Deprivation). RESULTS We included 31,414 cases of stroke with an equal number of matched controls. Overall, 83.2% of cases and controls were aged 65 years or older, and there were similar proportions of females (51.5%) and males (48.5%). Bisphosphonate treatment was not associated with stroke after adjusting for the wide range of confounders considered (OR 0.86, 95% CI 0.62-1.19). CONCLUSIONS We found no association between bisphosphonate treatment and risk of stroke, after adjusting for other confounders.
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Affiliation(s)
- Z B Asghar
- Mathematical Modelling and Statistics, Community and Health Research Unit, School of Health and Social Care, College of Social Science, University of Lincoln, Brayford Campus, Lincoln, LN6 7TS, UK.
| | - A Godoy Caballero
- Community and Health Research Unit, School of Health and Social Care, College of Social Science, University of Lincoln, Brayford Campus, Lincoln, LN6 7TS, UK
| | - S Pathirannehelage
- Section of Clinical Medicine and Ageing, Department of Clinical and Experimental Medicine, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Surrey, GU2 7XH, UK
| | - J Williams
- Section of Clinical Medicine and Ageing, Department of Clinical and Experimental Medicine, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Surrey, GU2 7XH, UK
| | - S McKay
- School of Social and Political Sciences, College of Social Science, School of Social Policy, CSS, University of Lincoln, Brayford Campus, Lincoln, LN6 7TS, UK
| | - P Grassby
- School of Pharmacy, College of Science, University of Lincoln, Brayford Campus, Lincoln, LN6 7TS, UK
| | - S de Lusignan
- Primary Care and Clinical Informatics, Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - A Niroshan Siriwardena
- Primary & Pre-Hospital Health Care, Community and Health Research Unit, School of Health and Social Care, College of Social Science, University of Lincoln, Brayford Campus, Lincoln, LN6 7TS, UK
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20
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Kirchmayer U, Sorge C, Sultana J, Lapi F, Onder G, Agabiti N, Cascini S, Roberto G, Corrao G, Vitale C, Lucenteforte E, Mugelli A, Davoli M. Bisphosphonates and cardiovascular risk in elderly patients with previous cardiovascular disease: a population-based nested case-control study in Italy. Ther Adv Drug Saf 2019; 10:2042098619838138. [PMID: 31057787 PMCID: PMC6452576 DOI: 10.1177/2042098619838138] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/18/2019] [Indexed: 01/05/2023] Open
Abstract
Background: In a globally aging population, chronic conditions with a high impact on healthcare costs and quality of life, such as osteoporosis and associated fractures, are a matter of concern. For osteoporosis, several drug treatments are available, but evidence on adverse cardiovascular and cerebrovascular (CCV) events, and in particular the risk of atrial fibrillation (AF), related to anti-osteoporotic drug use is inconclusive. The objective of this study was to evaluate the association between the use of bisphosphonates (BPs), strontium ranelate (SR), and other anti-osteoporosis drugs and the risk of AF and CCV events in a large cohort of patients affected by CCV diseases. Methods: Based on a cohort of patients aged 65 years and over, discharged from the hospitals of five large Italian areas after a CCV event between 2008 and 2011, two nested case-control studies were conducted. Cases were patients with a subsequent hospital admission for AF or CCV; four controls for each case were randomly selected and matched by age group, sex and follow-up time. A total of three exposure measures were tested: ever use, adherence and recency of use. In the conditional logistic regression models, patients not treated with any anti-osteoporotic medication were considered as the reference category. Results: The initial cohort accounted for 657,246 patients. Neither BPs nor SR use was associated with an increased risk of AF regardless of the adherence and recency of use. Overall BP and SR use was associated with a slightly increased risk of CCV; however, results reversed when considering higher adherence: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.71–0.92 for BPs and OR 0.71, 95% CI 0.52–0.97 for SR. Conclusions: BPs do not increase cardiovascular risk and can be prescribed to elderly patients for osteoporosis treatment. However, patients with pre-existing cerebrovascular/cardiovascular conditions should be carefully monitored.
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Affiliation(s)
- Ursula Kirchmayer
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Chiara Sorge
- Department of Epidemiology, Lazio Regional Health Service, ASL Roma 1, Via Cristoforo Colombo 112, Rome, 00147, Italy
| | - Janet Sultana
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Francesco Lapi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Graziano Onder
- Department of Geriatrics, Catholic University of Rome, Rome, Italy
| | - Nera Agabiti
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Silvia Cascini
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Giuseppe Roberto
- Epidemiology Unit, Regional Agency for Healthcare Services of Tuscany, Florence, Italy
| | - Giovanni Corrao
- Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Cristiana Vitale
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy
| | - Ersilia Lucenteforte
- Department of Neurosciences, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Alessandro Mugelli
- Department of Neurosciences, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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Abstract
Thyroid hormone suppression therapy is designed to lower serum thyrotropin (TSH) levels using doses of thyroid hormone in excess of what would normally be required to maintain a euthyroid state. The basis of this therapy is the knowledge that TSH is a growth factor for thyroid cancer, so that lower serum TSH levels might be associated with decreased disease activity. However, clinical studies have not documented improved outcomes with TSH suppression, except in patients with the most advanced disease. Furthermore, there are a number of negative outcomes related to aggressive thyroid hormone therapy, including osteoporosis, fracture, and cardiovascular disease. Therefore, a graded approach to TSH suppression is recommended by the American Thyroid Association, based on initial risk and ongoing risk assessment.
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Affiliation(s)
- Bernadette Biondi
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, Naples 80131, Italy
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD 21287, USA.
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Camacho PM, Petak SM, Binkley N, Clarke BL, Harris ST, Hurley DL, Kleerekoper M, Lewiecki EM, Miller PD, Narula HS, Pessah-Pollack R, Tangpricha V, Wimalawansa SJ, Watts NB. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS - 2016. Endocr Pract 2019; 22:1-42. [PMID: 27662240 DOI: 10.4158/ep161435.gl] [Citation(s) in RCA: 305] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABBREVIATIONS AACE = American Association of Clinical Endocrinologists AFF = atypical femur fracture ASBMR = American Society for Bone and Mineral Research BEL = best evidence level BMD = bone mineral density BTM = bone turnover marker CBC = complete blood count CI = confidence interval DXA = dual-energy X-ray absorptiometry EL = evidence level FDA = U.S. Food and Drug Administration FLEX = Fracture Intervention Trial (FIT) Long-term Extension FRAX® = Fracture Risk Assessment Tool GFR = glomerular filtration rate GI = gastrointestinal HORIZON = Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly IOF = International Osteoporosis Foundation ISCD = International Society for Clinical Densitometry IU = international units IV = intravenous LSC = least significant change NBHA = National Bone Health Alliance NOF = National Osteoporosis Foundation 25(OH)D = 25-hydroxy vitamin D ONJ = osteonecrosis of the jaw PINP = serum carboxy-terminal propeptide of type I collagen PTH = parathyroid hormone R = recommendation RANK = receptor activator of nuclear factor kappa-B RANKL = receptor activator of nuclear factor kappa-B ligand RCT = randomized controlled trial RR = relative risk S-CTX = serum C-terminal telopeptide SQ = subcutaneous VFA = vertebral fracture assessment WHO = World Health Organization.
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23
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Gorenek B, Pelliccia A, Benjamin EJ, Boriani G, Crijns HJ, Fogel RI, Van Gelder IC, Halle M, Kudaiberdieva G, Lane DA, Larsen TB, Lip GYH, Løchen ML, Marín F, Niebauer J, Sanders P, Tokgozoglu L, Vos MA, Van Wagoner DR, Fauchier L, Savelieva I, Goette A, Agewall S, Chiang CE, Figueiredo M, Stiles M, Dickfeld T, Patton K, Piepoli M, Corra U, Marques-Vidal PM, Faggiano P, Schmid JP, Abreu A. European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society (HRS) and Asia Pacific Heart Rhythm Society (APHRS). Europace 2018; 19:190-225. [PMID: 28175283 DOI: 10.1093/europace/euw242] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | - Harry J Crijns
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Martin Halle
- Prevention and Sports Medicine, Technical University Munich, München, Germany
| | | | | | | | | | - Maja-Lisa Løchen
- University of Birmingham, Birmingham, UK.,Aalborg University Hospital, Aalborg, Denmark
| | | | - Josef Niebauer
- Paracelsus Medical University Salzburg, Salzburg, Austria
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ugo Corra
- Irccs Rehabilitation Medical Center, Veruno, Italy
| | | | | | | | - Ana Abreu
- Hospital de Santa Marta, Lisboa, Portugal
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24
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Abstract
Thyroid hormones are essential for skeletal development and are important regulators of bone maintenance in adults. Childhood hypothyroidism causes delayed skeletal development, retarded linear growth and impaired bone mineral accrual. Epiphyseal dysgenesis is evidenced by classic features of stippled epiphyses on X-ray. In severe cases, post-natal growth arrest results in a complex skeletal dysplasia. Thyroid hormone replacement stimulates catch-up growth and bone maturation, but recovery may be incomplete dependent on the duration and severity of hypothyroidism prior to treatment. A severe phenotype characteristic of hypothyroidism occurs in children with resistance to thyroid hormone due to mutations affecting THRA encoding thyroid hormone receptor α (TRα). Discovery of this rare condition recapitulated animal studies demonstrating that TRα mediates thyroid hormone action in the skeleton. In adults, thyrotoxicosis is well known to cause severe osteoporosis and fracture, but cases are rare because of prompt diagnosis and treatment. Recent data, however, indicate that subclinical hyperthyroidism is associated with low bone mineral density (BMD) and an increased risk of fracture. Population studies have also shown that variation in thyroid status within the reference range in post-menopausal women is associated with altered BMD and fracture risk. Thus, thyroid status at the upper end of the euthyroid reference range is associated with low BMD and increased risk of osteoporotic fragility fracture. Overall, extensive data demonstrate that euthyroid status is required for normal post-natal growth and bone mineral accrual, and is fundamental for maintenance of adult bone structure and strength.
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Affiliation(s)
- G. R. Williams
- Molecular Endocrinology Laboratory, Department of Medicine, Imperial College London, Hammersmith Campus, Du Cane Road, 10N5 Commonwealth Building, London, W12 0NN UK
| | - J. H. D. Bassett
- Molecular Endocrinology Laboratory, Department of Medicine, Imperial College London, Hammersmith Campus, Du Cane Road, 10N6 Commonwealth Building, London, W12 0NN UK
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25
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Freudenthal B, Williams G. Thyroid Stimulating Hormone Suppression in the Long-term Follow-up of Differentiated Thyroid Cancer. Clin Oncol (R Coll Radiol) 2017; 29:325-328. [DOI: 10.1016/j.clon.2016.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 01/08/2023]
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26
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Kyrgidis A, Yavropoulou MP, Lagoudaki R, Andreadis C, Antoniades K, Kouvelas D. Increased CD14+ and decreased CD14- populations of monocytes 48 h after zolendronic acid infusion in breast cancer patients. Osteoporos Int 2017; 28:991-999. [PMID: 27858122 DOI: 10.1007/s00198-016-3807-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 10/06/2016] [Indexed: 11/24/2022]
Abstract
UNLABELLED It has been proposed that bisphosphonates cause osteonecrosis of the jaws through impairment of the monocyte population function and proliferation. Such changes have been confirmed in jaw tissues, ex vivo. In this clinical study, we report for the first time a similar pattern of changes in peripheral blood monocytes. INTRODUCTION The aim of this study is to examine the effect of zolendronic acid administration in the peripheral blood white cell population, seeking a plausible pathophysiological link between bisphosphonates and osteonecrosis of the jaw. METHODS Twenty-four breast cancer patients, under zolendronic acid treatment for bone metastasis, were included. Peripheral blood samples were obtained prior to and 48 h following zolendronic acid administration. Flow cytometry gated at leukocyte, monocyte, and the granulocyte populations for the CD4/CD8/CD3, CD3/CD16+56/CD45/CD19, CD14/CD123, and CD14/23 stainings were performed. RESULTS We were able to record a number of changes in the white cell populations after 48 h of zolendronic acid administration. Most importantly, in the monocyte populations, we were able to detect statistically significant increased populations of CD14+/CD23+ (p = 0.038), CD14+/CD23- (p = 0.028), CD14+/CD123+ (p = 0.070, trend), and CD14+/CD123- (p = 0.043). In contrast, statistically significant decreased populations of CD14-/CD23+ (p = 0.037) and CD14-/CD123+ (p = 0.003) were detected. CONCLUSIONS Our results provide evidence supporting the hypothesis that bisphosphonate administration modifies the monocyte-mediated immune response. An increase of CD14+ peripheral blood monocyte (PBMC) populations along with a decrease of CD14- PBMC populations has been recorded. The latter finding is in accordance with limited-currently existing-evidence and warrants further elucidation.
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Affiliation(s)
- A Kyrgidis
- Department of Pharmacology, Clinical Pharmacology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - M P Yavropoulou
- Laboratory of Clinical and Molecular Endocrinology, 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - R Lagoudaki
- Department of Neurology, AHEPA University Hospital, Thessaloniki, Greece
| | - C Andreadis
- 3rd Department of Clinical Oncology, Theagenio Cancer Hospital, Thessaloniki, Greece
| | - K Antoniades
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - D Kouvelas
- Department of Pharmacology, Clinical Pharmacology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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27
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Gorenek B, Pelliccia A, Benjamin EJ, Boriani G, Crijns HJ, Fogel RI, Van Gelder IC, Halle M, Kudaiberdieva G, Lane DA, Bjerregaard Larsen T, Lip GYH, Løchen ML, Marin F, Niebauer J, Sanders P, Tokgozoglu L, Vos MA, Van Wagoner DR, Fauchier L, Savelieva I, Goette A, Agewall S, Chiang CE, Figueiredo M, Stiles M, Dickfeld T, Patton K, Piepoli M, Corra U, Manuel Marques-Vidal P, Faggiano P, Schmid JP, Abreu A. European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society (HRS) and Asia Pacific Heart Rhythm Society (APHRS). Eur J Prev Cardiol 2017; 24:4-40. [PMID: 27815538 PMCID: PMC5427484 DOI: 10.1177/2047487316676037] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | | | | | | | - Harry J Crijns
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Martin Halle
- Prevention and Sports Medicine, Technical University Munich, München, Germany
| | | | | | | | | | - Maja-Lisa Løchen
- UiT The Arctic University of Norway, Tromso, Norway
- Mary MacKillop Institute for Health Research, Centre for Research Excellence to Reduce Inequality in Heart Disease, Australian Catholic University, Melbourne, Australia
| | | | - Josef Niebauer
- Paracelsus Medical University Salzburg, Salzburg, Austria
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ugo Corra
- Irccs Rehabilitation Medical Center, Veruno, Italy
| | | | | | | | - Ana Abreu
- Hospital de Santa Marta, Lisboa, Portugal
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28
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Aktas I, Nazikoglu C, Kepez A, Ozkan FU, Kaysin MY, Akpinar P, Dogan Z, Ileri C, Saymaz S, Erdogan O. Effect of intravenous zoledronic acid infusion on electrocardiographic parameters in patients with osteoporosis. Osteoporos Int 2016; 27:3543-3547. [PMID: 27344642 DOI: 10.1007/s00198-016-3684-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 06/20/2016] [Indexed: 12/27/2022]
Abstract
UNLABELLED We evaluated the effects of zoledronic acid (ZA) therapy on electrocardiographic (ECG) parameters for the first time in the literature. Measurements were performed on ECGs obtained before and after ZA infusion on the same day as well as 1 month after the infusion. ZA infusion did not have any short- or long-term effect on any parameter that might be associated with the tendency for atrial fibrillation or ventricular arrhythmias. INTRODUCTION The aim of the present study was to evaluate the early and late effects of ZA therapy on ECG parameters which might be associated with the tendency for atrial and ventricular arrhythmias. METHODS Consecutive patients with osteoporosis who were admitted to our clinic between December 2013 and December 2014 and who were scheduled to receive ZA infusion constituted our study population. Twelve-lead surface ECGs were obtained from all patients before and after ZA infusion on the same day as well as 1 month after the infusion. All ECG parameters were measured and compared with each other for each patient. RESULTS Data of 100 patients were used in the analysis (9 male; 70.5 ± 11.6 years of age). There were no significant differences between repeated measurements regarding pmax, pmin, and p dispersion values. QT max and QT min values were significantly increased after infusion; however, there were no significant changes in QT dispersion, Tp-e interval, and Tp-e dispersion values. CONCLUSIONS ZA infusion did not affect P wave dispersion both at the immediate post-infusion period and 1 month after infusion. QT values were significantly increased early after ZA infusion; however, there were no significant differences in parameters reflecting disparity of ventricular recovery times and transmural dispersion of ventricular repolarization. Based on these observations, it may be suggested that ZA infusion did not have any short- or long-term effect on any parameter that might be associated with the tendency for atrial fibrillation or ventricular arrhythmias.
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Affiliation(s)
- I Aktas
- Physical Therapy and Rehabilitation Clinic, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - C Nazikoglu
- Family Medicine Clinic, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - A Kepez
- Cardiology Clinic, Marmara University Training and Research Hospital, Pendik, Istanbul, Turkey.
| | - F U Ozkan
- Physical Therapy and Rehabilitation Clinic, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - M Y Kaysin
- Physical Therapy and Rehabilitation Clinic, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - P Akpinar
- Physical Therapy and Rehabilitation Clinic, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Z Dogan
- Cardiology Clinic, Marmara University Training and Research Hospital, Pendik, Istanbul, Turkey
| | - C Ileri
- Cardiology Clinic, Marmara University Training and Research Hospital, Pendik, Istanbul, Turkey
| | - S Saymaz
- Cardiology Clinic, Marmara University Training and Research Hospital, Pendik, Istanbul, Turkey
| | - O Erdogan
- Cardiology Clinic, Marmara University Training and Research Hospital, Pendik, Istanbul, Turkey
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29
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Sasso GRDS, Florencio-Silva R, Simões RS, Baracat MCP, Soares Júnior JM, Baracat EC. Elevated serum osteoprotegerin levels in women: friend or foe? Rev Assoc Med Bras (1992) 2016; 61:524-9. [PMID: 26841162 DOI: 10.1590/1806-9282.61.06.524] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/08/2015] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION osteoprotegerin has emerged as a new candidate for the treatment of osteoporosis. However, high levels of osteoprotegerin have been linked to vascular calcification, an independent and well-defined risk factor for cardiovascular disease (CVD) and mortality. Thus, the action of osteoprotegerin in these situations has been questioned. OBJECTIVE to evaluate the effect of osteoprotegerin (OPG) on the human body, especially in bone tissue and in vascular diseases. METHODS the scientific databases consulted were PubMed-Medline and Cochrane, using keywords (MeSH terms) grouped into the following syntaxes: (Osteoprotegerin OR Osteoclastogenesis Inhibitory Factor OR Receptors, Tumor Necrosis Factor, Member 11b OR Tumor Necrosis Factor Receptor Superfamily, Member 11b OR FDCR-1 Protein OR FDCR 1 Protein OR OCIF Protein OR Follicular Dendritic Cell-Derived Receptor-1) AND (Bones AND Bone OR Bones AND Bone Tissue OR Bones OR Bone Tissue OR Cardiovascular Diseases). RESULTS Osteoprotegerin is present in various organs and binds to two ligands: nuclear factor kB (RANKL) related to the differentiation of osteoclasts, and tumor necrosis factor related to the apoptosis-inducing ligand (TRAIL). OPG inhibits the regulation effects of nuclear factor kB on inflammation and on the skeletal and vascular systems, preventing the apoptosis induced by TRAIL, being related to the preservation of bone tissue. CONCLUSION a deeper knowledge of the mechanisms involved in the association between OPG serum levels, bone integrity and cardiovascular disease can provide important data for future therapeutic interventions.
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Affiliation(s)
| | | | - Ricardo Santos Simões
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - José Maria Soares Júnior
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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30
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Wang ZC, Ji WH, Ruan CW, Liu XY, Qiu XB, Yuan F, Li RG, Xu YJ, Liu X, Huang RT, Xue S, Yang YQ. Prevalence and Spectrum of TBX5 Mutation in Patients with Lone Atrial Fibrillation. Int J Med Sci 2016; 13:60-7. [PMID: 26917986 PMCID: PMC4747871 DOI: 10.7150/ijms.13264] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 11/09/2015] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF), the most common type of cardiac rhythm disturbance encountered in clinical practice, is associated with substantially increased morbidity and mortality. Aggregating evidence demonstrates that abnormal cardiovascular development is involved in the pathogenesis of AF. A recent study has revealed that the TBX5 gene, which encodes a T-box transcription factor key to cardiovascular development, was associated with AF and atypical Holt-Oram syndrome. However, the prevalence and spectrum of TBX5 mutation in patients with lone AF remain unclear. In this study, the coding regions and splicing junction sites of TBX5 were sequenced in 192 unrelated patients with lone AF and 300 unrelated ethnically-matched healthy individuals used as controls. The causative potential of the identified TBX5 variation was evaluated by MutationTaster and PolyPhen-2. The functional effect of the mutant TBX5 was assayed by using a dual-luciferase reporter assay system. As a result, a novel heterozygous TBX5 mutation, p.H170D, was identified in a patient, with a mutational prevalence of approximately 0.52%. This mutation, which was absent in the 300 control individuals, altered the amino acid completely conserved evolutionarily across species, and was predicted to be disease-causing. Functional deciphers showed that the mutant TBX5 was associated with significantly reduced transcriptional activity when compared with its wild-type counterpart. Furthermore, the mutation significantly decreased the synergistic activation between TBX5 and NKX2-5 or GATA4. The findings expand the mutational spectrum of TBX5 linked to AF and provide new evidence that dysfunctional TBX5 may contribute to lone AF.
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Affiliation(s)
- Zhan-Cheng Wang
- 1. Department of Cardiology, Shanghai Eighth People's Hospital, 8 Caobao Road, Shanghai 200235, China
| | - Wen-Hui Ji
- 2. Department of Internal Medicine, Huajing Community Health Service Center of Xu Hui Distric, 180 Jianhua Road, Shanghai 200231, China
| | - Chang-Wu Ruan
- 1. Department of Cardiology, Shanghai Eighth People's Hospital, 8 Caobao Road, Shanghai 200235, China
| | - Xing-Yuan Liu
- 3. Department of Pediatrics, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Shanghai 200065, China
| | - Xing-Biao Qiu
- 4. Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Shanghai 200030, China
| | - Fang Yuan
- 4. Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Shanghai 200030, China
| | - Ruo-Gu Li
- 4. Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Shanghai 200030, China
| | - Ying-Jia Xu
- 4. Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Shanghai 200030, China
| | - Xu Liu
- 4. Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Shanghai 200030, China
| | - Ru-Tai Huang
- 5. Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Song Xue
- 5. Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Yi-Qing Yang
- 4. Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Shanghai 200030, China;; 6. Department of Cardiovascular Research Laboratory, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Shanghai 200030, China;; 7. Department of Central Laboratory, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Shanghai 200030, China
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31
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Kim DH, Rogers JR, Fulchino LA, Kim CA, Solomon DH, Kim SC. Bisphosphonates and risk of cardiovascular events: a meta-analysis. PLoS One 2015; 10:e0122646. [PMID: 25884398 PMCID: PMC4401508 DOI: 10.1371/journal.pone.0122646] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 02/23/2015] [Indexed: 11/23/2022] Open
Abstract
Background and Objectives Some evidence suggests that bisphosphonates may reduce atherosclerosis, while concerns have been raised about atrial fibrillation. We conducted a meta-analysis to determine the effects of bisphosphonates on total adverse cardiovascular (CV) events, atrial fibrillation, myocardial infarction (MI), stroke, and CV death in adults with or at risk for low bone mass. Methods A systematic search of MEDLINE and EMBASE through July 2014 identified 58 randomized controlled trials with longer than 6 months in duration that reported CV events. Absolute risks and the Mantel-Haenszel fixed-effects odds ratios (ORs) and 95% confidence intervals (CIs) of total CV events, atrial fibrillation, MI, stroke, and CV death were estimated. Subgroup analyses by follow-up duration, population characteristics, bisphosphonate types, and route were performed. Results Absolute risks over 25–36 months in bisphosphonate-treated versus control patients were 6.5% versus 6.2% for total CV events; 1.4% versus 1.5% for atrial fibrillation; 1.0% versus 1.2% for MI; 1.6% versus 1.9% for stroke; and 1.5% versus 1.4% for CV death. Bisphosphonate treatment up to 36 months did not have any significant effects on total CV events (14 trials; ORs [95% CI]: 0.98 [0.84–1.14]; I2 = 0.0%), atrial fibrillation (41 trials; 1.08 [0.92–1.25]; I2 = 0.0%), MI (10 trials; 0.96 [0.69–1.34]; I2 = 0.0%), stroke (10 trials; 0.99 [0.82–1.19]; I2 = 5.8%), and CV death (14 trials; 0.88 [0.72–1.07]; I2 = 0.0%) with little between-study heterogeneity. The risk of atrial fibrillation appears to be modestly elevated for zoledronic acid (6 trials; 1.24 [0.96–1.61]; I2 = 0.0%), not for oral bisphosphonates (26 trials; 1.02 [0.83–1.24]; I2 = 0.0%). The CV effects did not vary by subgroups or study quality. Conclusions Bisphosphonates do not have beneficial or harmful effects on atherosclerotic CV events, but zoledronic acid may modestly increase the risk of atrial fibrillation. Given the large reduction in fractures with bisphosphonates, changes in osteoporosis treatment decision due to CV risk are not justified.
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Affiliation(s)
- Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - James R. Rogers
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Lisa A. Fulchino
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Caroline A. Kim
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Daniel H. Solomon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Seoyoung C. Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Rocca WA, Boyd CM, Grossardt BR, Bobo WV, Finney Rutten LJ, Roger VL, Ebbert JO, Therneau TM, Yawn BP, St Sauver JL. Prevalence of multimorbidity in a geographically defined American population: patterns by age, sex, and race/ethnicity. Mayo Clin Proc 2014; 89:1336-49. [PMID: 25220409 PMCID: PMC4186914 DOI: 10.1016/j.mayocp.2014.07.010] [Citation(s) in RCA: 166] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 07/22/2014] [Accepted: 07/23/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe the prevalence of multimorbidity involving 20 selected chronic conditions in a geographically defined US population, emphasizing age, sex, and racial/ethnic differences. PATIENTS AND METHODS Using the Rochester Epidemiology Project records linkage system, we identified all residents of Olmsted County, Minnesota, on April 1, 2010, and electronically extracted the International Classification of Diseases, Ninth Revision codes associated with all health care visits made between April 1, 2005, and March 31, 2010 (5-year capture frame). Using these codes, we defined the 20 common chronic conditions recommended by the US Department of Health and Human Services. We counted only persons who received at least 2 codes for a given condition separated by more than 30 days, and we calculated the age-, sex-, and race/ethnicity-specific prevalence of multimorbidity. RESULTS Of the 138,858 study participants, 52.4% were women (n=72,732) and 38.9% had 1 or more conditions (n=54,012), 22.6% had 2 or more conditions (n=31,444), and 4.9% had 5 or more conditions (n=6853). The prevalence of multimorbidity (≥2 conditions) increased steeply with older age and reached 77.3% at 65 years and older. However, the absolute number of people affected by multimorbidity was higher in those younger than 65 years. Although the prevalence of multimorbidity was similar in men and women overall, the most common dyads and triads of conditions varied by sex. Compared with white persons, the prevalence of multimorbidity was slightly higher in black persons and slightly lower in Asian persons. CONCLUSION Multimorbidity is common in the general population; it increases steeply with older age, has different patterns in men and women, and varies by race/ethnicity.
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Affiliation(s)
- Walter A Rocca
- Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN; Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN.
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Brandon R Grossardt
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN
| | - William V Bobo
- Department of Psychiatry, College of Medicine, Mayo Clinic, Rochester, MN
| | - Lila J Finney Rutten
- Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, College of Medicine, Mayo Clinic, Rochester, MN
| | - Véronique L Roger
- Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN; Division of Cardiovascular Diseases, Department of Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, College of Medicine, Mayo Clinic, Rochester, MN
| | - Jon O Ebbert
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, College of Medicine, Mayo Clinic, Rochester, MN
| | - Terry M Therneau
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN
| | - Barbara P Yawn
- Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN; Department of Research, Olmsted Medical Center, Rochester, MN
| | - Jennifer L St Sauver
- Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, College of Medicine, Mayo Clinic, Rochester, MN
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33
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Williams GR. Is prophylactic anti-resorptive therapy required in thyroid cancer patients receiving TSH-suppressive treatment with thyroxine? J Endocrinol Invest 2014; 37:775-779. [PMID: 24939818 DOI: 10.1007/s40618-014-0110-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 05/30/2014] [Indexed: 12/24/2022]
Affiliation(s)
- Graham R Williams
- Molecular Endocrinology Group, Department of Medicine, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.
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