1
|
Kim AS, Taylor VE, Castro-Martinez A, Dhakal S, Zamerli A, Mohanty S, Xiao Y, Simic MK, Wen J, Chai R, Croucher PI, Center JR, Girgis CM, McDonald MM. Temporal patterns of osteoclast formation and activity following withdrawal of RANKL inhibition. J Bone Miner Res 2024; 39:484-497. [PMID: 38477789 DOI: 10.1093/jbmr/zjae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 03/14/2024]
Abstract
Rebound bone loss following denosumab discontinuation is an important clinical challenge. Current treatment strategies to prevent this fail to suppress the rise and overshoot in osteoclast-mediated bone resorption. In this study, we use a murine model of denosumab treatment and discontinuation to show the temporal changes in osteoclast formation and activity during RANKL inhibition and withdrawal. We show that the cellular processes that drive the formation of osteoclasts and subsequent bone resorption following withdrawal of RANKL inhibition precede the rebound bone loss. Furthermore, a rise in serum TRAP and RANKL levels is detected before markers of bone turnover used in current clinical practice. These mechanistic advances may provide insight into a more defined window of opportunity to intervene with sequential therapy following denosumab discontinuation.
Collapse
Affiliation(s)
- Albert S Kim
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, 2010, Australia
- Faculty of Medicine, St Vincent's Clinical School, UNSW Sydney, Sydney, NSW, 2010, Australia
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, NSW, 2145, Australia
- Faculty of Health and Medicine, University of Sydney, Sydney, NSW, 2050, Australia
| | - Victoria E Taylor
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, 2010, Australia
| | - Ariel Castro-Martinez
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, 2010, Australia
| | - Suraj Dhakal
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, 2010, Australia
| | - Amjad Zamerli
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, 2010, Australia
| | - Sindhu Mohanty
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, 2010, Australia
| | - Ya Xiao
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, 2010, Australia
| | - Marija K Simic
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, 2010, Australia
- Department of Pathology, New York University Grossman School of Medicine, New York, NY, 10016, United States
| | - Jinchen Wen
- Department of Psychology and Neuroscience, Duke University, Durham, NC, 27708, United States
| | - Ryan Chai
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, 2010, Australia
- Faculty of Medicine, St Vincent's Clinical School, UNSW Sydney, Sydney, NSW, 2010, Australia
| | - Peter I Croucher
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, 2010, Australia
- Faculty of Medicine, St Vincent's Clinical School, UNSW Sydney, Sydney, NSW, 2010, Australia
| | - Jacqueline R Center
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, 2010, Australia
- Faculty of Medicine, St Vincent's Clinical School, UNSW Sydney, Sydney, NSW, 2010, Australia
| | - Christian M Girgis
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, NSW, 2145, Australia
- Faculty of Health and Medicine, University of Sydney, Sydney, NSW, 2050, Australia
| | - Michelle M McDonald
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, 2010, Australia
- Faculty of Medicine, St Vincent's Clinical School, UNSW Sydney, Sydney, NSW, 2010, Australia
- Faculty of Health and Medicine, University of Sydney, Sydney, NSW, 2050, Australia
| |
Collapse
|
2
|
Cosman F, Langdahl B, Leder BZ. Treatment Sequence for Osteoporosis. Endocr Pract 2024; 30:490-496. [PMID: 38311211 DOI: 10.1016/j.eprac.2024.01.014] [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] [Received: 12/09/2023] [Revised: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Osteoporosis is a chronic progressive disease that requires lifelong monitoring and treatment. Sequencing from one treatment to another at different ages and stages of disease is an approach that can maximize benefits and avoid potential risks from long-term treatment with a single agent. OBJECTIVE This article reviews clinical trial data in postmenopausal women that evaluate the effects of antiresorptive agents followed by other antiresorptives, osteoanabolic agents followed by antiresorptives, and antiresorptives followed by osteoanabolic medications. METHODS Literature review and discussion. RESULTS When medications are discontinued, in the absence of sequential therapy, bone turnover rates return to baseline or above baseline, and bone loss occurs. The rate of bone loss differs for different treatments, with a very slow decline after stopping bisphosphonates and a particularly rapid decline after stopping denosumab. Careful attention to osteoporosis medication transitions can mitigate bone density loss and its consequences. For women who remain at high risk, switching from bisphosphonates to the more potent antiresorptive, denosumab, will result in further improvement in bone mineral density (BMD). When indicated, stopping denosumab can be accomplished safely by transition to an adequate bisphosphonate regimen. For high- and very-high-risk patients, treating with osteoanabolic agents first, followed by antiresorptive agents, produces substantially larger BMD gains than the reverse treatment sequence, with the biggest differences seen for BMD of the hip. CONCLUSION Awareness of the importance of treatment sequences can help improve osteoporosis care across the postmenopausal lifespan.
Collapse
Affiliation(s)
- Felicia Cosman
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York.
| | - Bente Langdahl
- Department of Endocrinology and Metabolic Bone Diseases, Aarhus University Hospital and Aarhus University, Aarhus, Denmark.
| | - Benjamin Z Leder
- Department of Medicine, Harvard Medical School, Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts.
| |
Collapse
|
3
|
Razi F, Ostovar A, Fahimfar N, M. Amoli M, Fana SE, Dimai HP, Obermayer-Pietsch B, Luegger B, Rivadeneira F, Nabipour I, Larijani B, Khashayar P. Protocol for preliminary, multicenteric validation of "PoCOsteo device": A point of care tool for proteomic and genomic study of osteoporosis. Biol Methods Protoc 2024; 9:bpae006. [PMID: 38559752 PMCID: PMC10978377 DOI: 10.1093/biomethods/bpae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/26/2024] [Accepted: 03/21/2024] [Indexed: 04/04/2024] Open
Abstract
One of the goals of the HORIZON 2020 project PoCOsteo was to develop a medical device, which would measure and/or quantify proteomic as well as genomic factors as present in whole blood samples collected through finger prick. After validating the tool in the clinical setting, the next step would be its clinical validation based on the existing guidelines. This article presents the protocol of a validation study to be carried out independently at two different centers (Division of Endocrinology and Diabetology at the Medical University of Graz as a clinic-based cohort, and the Endocrinology and Metabolism Research Institute at the Tehran University of Medical Sciences as a population-based cohort). It aims to assess the tool according to the Clinical & Laboratory Standards Institute guidelines, confirming if the proteomics and genomics measurements provided by the tool are accurate and reproducible compared with the existing state-of-the-art tests. This is the first time that such a detailed protocol for lab validation of a medical tool for proteomics and genomic measurement is designed based on the existing guidelines and thus could be used as a template for clinical validation of future point-of-care tools. Moreover, the multicentric cohort design will allow the study of a large number of diverse individuals, which will improve the validity and generalizability of the results for different settings.
Collapse
Affiliation(s)
- Farideh Razi
- Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Afshin Ostovar
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Noushin Fahimfar
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa M. Amoli
- Metabolic Disorders Research Center (MDRC), Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Saeed Ebrahimi Fana
- Department of Clinical Biochemistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Hans Peter Dimai
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - Barbara Obermayer-Pietsch
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - Barbara Luegger
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | | | - Iraj Nabipour
- The Persian Gulf Marine Biotechnology Research Center, The Persian Gulf Biomedical Sciences Research Institute, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Patricia Khashayar
- Center for Microsystems Technology, Imec & Ghent University, Zwijnaarde, Gent, Belgium
| |
Collapse
|
4
|
Sauhta R, Makkar D, Siwach PS. The Sequential Therapy in Osteoporosis. Indian J Orthop 2023; 57:150-162. [PMID: 38107815 PMCID: PMC10721775 DOI: 10.1007/s43465-023-01067-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/15/2023] [Indexed: 12/19/2023]
Abstract
Background Osteoporosis management often involves a sequential treatment approach to optimize patient outcomes and minimize fracture risks. This strategy is tailored to individual patient characteristics, treatment responses, and fracture risk profiles. Methods A thorough literature review was systematically executed using prominent databases, including PubMed and EMBASE. The primary aim was to identify original articles and clinical trials evaluating the effectiveness of sequential therapy with anti-osteoporosis drugs, focusing on the period from 1995 to 2023. The analysis encompassed an in-depth examination of osteoporosis drugs, delineating their mechanisms of action, side effects, and current trends as elucidated in the literature. Results and Discussion Our study yielded noteworthy insights into the optimal sequencing of pharmacologic agents for the long-term treatment of patients necessitating multiple drugs. Notably, the achievement of optimal improvements in bone mass is observed when commencing treatment with an anabolic medication, followed by the subsequent utilization of an antiresorptive drug. This stands in contrast to initiating therapy with a bisphosphonate, which may potentially diminish outcomes in the post-anabolic intervention period. Furthermore, it has been discerned that caution should be exercised against transitioning from denosumab to PTH homologs due to the adverse effects of heightened bone turnover and sustained weakening of bone structure. Despite the absence of fracture data substantiating the implementation of integrated anabolic/antiresorptive pharmacotherapy, the incorporation of denosumab and teriparatide presents a potential avenue worthy of consideration for individuals at a heightened vulnerability to fragility fractures. Conclusions A judiciously implemented sequential treatment strategy in osteoporosis offers a flexible and tailored approach to address diverse clinical scenarios, optimizing fracture prevention and patient outcomes.
Collapse
Affiliation(s)
- Ravi Sauhta
- Department Orthopedics and Joint
Replacement, Artemis Hospitals, Gurgaon, India
| | | | | |
Collapse
|
5
|
Chandran M. The why and how of sequential and combination therapy in osteoporosis. A review of the current evidence. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:724-738. [PMID: 36382762 PMCID: PMC10118820 DOI: 10.20945/2359-3997000000564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
It is now well recognized that over the lifetime of a patient with osteoporosis, more than one medication will be needed to treat the disease and to decrease fracture risk. Though current gaps in osteoporosis therapy can be potentially mitigated with sequential and combination regimens, how to move seamlessly amongst the multiple treatments currently available for osteoporosis for sustained efficacy is still unclear. Data from recent studies show that an anabolic agent such as teriparatide or romosozumab followed by an antiresorptive affords maximal gain in BMD and possibly better and earlier fracture risk reduction compared to a regimen which follows the opposite sequence. Sequentially moving to a bisphosphonate such as alendronate from an anabolic agent such as abaloparatide has also been shown to preserve the fracture reduction benefits seen with the latter. This sequence of an anabolic agent followed by an antiresorptive should especially be considered in the high-risk patient with imminent fracture risk to rapidly reduce the risk of subsequent fractures. The data surrounding optimum timing of initiation of bisphosphonate therapy following denosumab discontinuation is still unclear. Though data suggests that combining a bisphosphonate with teriparatide does not provide substantial BMD gains compared to monotherapy, the concomitant administration of denosumab with teriparatide has been shown to significantly increase areal BMD as well as to increase volumetric BMD and estimated bone strength. This narrative review explores the available evidence regarding the various sequential and combination therapy approaches and the potential role they could play in better managing osteoporosis.
Collapse
|
6
|
Hwang JS, Lee S, Gong HS. The impact of acute fracture on interpretation of bone turnover marker measurements for patients starting anti-resorptive therapies. Bone 2022; 154:116199. [PMID: 34534710 DOI: 10.1016/j.bone.2021.116199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Bone turnover markers (BTM) are used in evaluating patients' response to anti-resorptive agents (ARA). Fracture and its healing process, however, can influence the measurements, which might make their interpretation difficult in patients with a recent fracture. We aimed to evaluate the effect of oral ARA on changes in BTM levels in patients with a recent distal radius fracture (DRF). METHODS In 143 women who had a new DRF and then received oral ARA including selective estrogen receptor modulator (SERM, n = 101), and bisphosphonate (n = 42), we measured serum cross-linked C-telopeptides of type I collagen (CTXI) and osteocalcin, at baseline and six months, as well as lumbar and total hip bone mineral density (BMD) at baseline and one year after fracture. We determined the predictive value of BTM at six months in determining one-year responses in BMD. RESULTS Both BTM levels decreased significantly at six months, with the average decrease of 27 ± 63% for CTX-I and 11% ± 37% for osteocalcin. The percent changes of BTM at six months were independent predictors of the BMD change. Cutoff points of 50.0% CTX-I decrease and 23.5% for osteocalcin decrease had the highest sensitivities and specificities for detecting BMD responders for bisphosphonate users, but cutoffs could not be found for SERM users. CONCLUSION Although a fresh fracture can influence BTM, ARA therapy significantly reduced their levels and their percent change at six months could predict BMD improvement at one year. However, adjusted cutoff points can be necessary to increase sensitivity for detecting patients responsive to ARA treatment after a new DRF.
Collapse
Affiliation(s)
- Ji Sup Hwang
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, South Korea
| | - Sanguk Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, South Korea
| | - Hyun Sik Gong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, South Korea.
| |
Collapse
|
7
|
Davis S, Simpson E, Hamilton J, James MMS, Rawdin A, Wong R, Goka E, Gittoes N, Selby P. Denosumab, raloxifene, romosozumab and teriparatide to prevent osteoporotic fragility fractures: a systematic review and economic evaluation. Health Technol Assess 2021; 24:1-314. [PMID: 32588816 DOI: 10.3310/hta24290] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture. OBJECTIVES The objectives were to evaluate the clinical effectiveness, safety and cost-effectiveness of non-bisphosphonates {denosumab [Prolia®; Amgen Inc., Thousand Oaks, CA, USA], raloxifene [Evista®; Daiichi Sankyo Company, Ltd, Tokyo, Japan], romosozumab [Evenity®; Union Chimique Belge (UCB) S.A. (Brussels, Belgium) and Amgen Inc.] and teriparatide [Forsteo®; Eli Lilly and Company, Indianapolis, IN, USA]}, compared with each other, bisphosphonates or no treatment, for the prevention of fragility fracture. DATA SOURCES For the clinical effectiveness review, nine electronic databases (including MEDLINE, EMBASE and the World Health Organization International Clinical Trials Registry Platform) were searched up to July 2018. REVIEW METHODS A systematic review and network meta-analysis of fracture and femoral neck bone mineral density were conducted. A review of published economic analyses was undertaken and a model previously used to evaluate bisphosphonates was adapted. Discrete event simulation was used to estimate lifetime costs and quality-adjusted life-years for a simulated cohort of patients with heterogeneous characteristics. This was done for each non-bisphosphonate treatment, a strategy of no treatment, and the five bisphosphonate treatments previously evaluated. The model was populated with effectiveness evidence from the systematic review and network meta-analysis. All other parameters were estimated from published sources. An NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Fracture risk was estimated from patient characteristics using the QFracture® (QFracture-2012 open source revision 38, Clinrisk Ltd, Leeds, UK) and FRAX® (web version 3.9, University of Sheffield, Sheffield, UK) tools. The relationship between fracture risk and incremental net monetary benefit was estimated using non-parametric regression. A probabilistic sensitivity analysis and scenario analyses were used to assess uncertainty. RESULTS Fifty-two randomised controlled trials of non-bisphosphonates were included in the clinical effectiveness systematic review and an additional 51 randomised controlled trials of bisphosphonates were included in the network meta-analysis. All treatments had beneficial effects compared with placebo for vertebral, non-vertebral and hip fractures, with hazard ratios varying from 0.23 to 0.94, depending on treatment and fracture type. The effects on vertebral fractures and the percentage change in bone mineral density were statistically significant for all treatments. The rate of serious adverse events varied across trials (0-33%), with most between-group differences not being statistically significant for comparisons with placebo/no active treatment, non-bisphosphonates or bisphosphonates. The incremental cost-effectiveness ratios were > £20,000 per quality-adjusted life-year for all non-bisphosphonate interventions compared with no treatment across the range of QFracture and FRAX scores expected in the population eligible for fracture risk assessment. The incremental cost-effectiveness ratio for denosumab may fall below £30,000 per quality-adjusted life-year at very high levels of risk or for high-risk patients with specific characteristics. Raloxifene was dominated by no treatment (resulted in fewer quality-adjusted life-years) in most risk categories. LIMITATIONS The incremental cost-effectiveness ratios are uncertain for very high-risk patients. CONCLUSIONS Non-bisphosphonates are effective in preventing fragility fractures, but the incremental cost-effectiveness ratios are generally greater than the commonly applied threshold of £20,000-30,000 per quality-adjusted life-year. STUDY REGISTRATION This study is registered as PROSPERO CRD42018107651. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 29. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Sarah Davis
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Simpson
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marrissa Martyn-St James
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Rawdin
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edward Goka
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Neil Gittoes
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter Selby
- School of Medical Sciences, University of Manchester, Manchester, UK
| |
Collapse
|
8
|
Karsdal MA, Genovese F, Rasmussen DGK, Bay-Jensen AC, Mortensen JH, Holm Nielsen S, Willumsen N, Jensen C, Manon-Jensen T, Jennings L, Reese-Petersen AL, Henriksen K, Sand JM, Bager C, Leeming DJ. Considerations for understanding protein measurements: Identification of formation, degradation and more pathological relevant epitopes. Clin Biochem 2021; 97:11-24. [PMID: 34453894 DOI: 10.1016/j.clinbiochem.2021.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/06/2021] [Accepted: 08/23/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES There is a need for precision medicine and an unspoken promise of an optimal approach for identification of the right patients for value-based medicine based on big data. However, there may be a misconception that measurement of proteins is more valuable than measurement of fewer selected biomarkers. In population-based research, variation may be somewhat eliminated by quantity. However, this fascination of numbers may limit the attention to and understanding of the single. This review highlights that protein measurements (with collagens as examples) may mean different things depending on the targeted epitope - formation or degradation of tissues, and even signaling potential of proteins. DESIGN AND METHODS PubMed was searched for collagen, neo-epitope, biomarkers. RESULTS Ample examples of assays with specific epitopes, either pathological such as HbA1c, or domain specific such as pro-peptides, which total protein arrays would not have identified were evident. CONCLUSIONS We suggest that big data may be considered as the funnel of data points, in which most important parameters will be selected. If the technical precision is low or the biological accuracy is limited, and we include suboptimal quality of biomarkers, disguised as big data, we may not be able to fulfill the promise of helping patients searching for the optimal treatment. Alternatively, if the technical precision of the total protein quantification is high, but we miss the functional domains with the most considerable biological meaning, we miss the most important and valuable information of a given protein. This review highlights that measurements of the same protein in different ways may provide completely different meanings. We need to understand the pathological importance of each epitope quantified to maximize protein measurements.
Collapse
Affiliation(s)
- M A Karsdal
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark.
| | - F Genovese
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark
| | - D G K Rasmussen
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark
| | - A C Bay-Jensen
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark
| | - J H Mortensen
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark
| | - S Holm Nielsen
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark
| | - N Willumsen
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark
| | - C Jensen
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark
| | - T Manon-Jensen
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark
| | | | | | - K Henriksen
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark
| | - J M Sand
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark
| | - C Bager
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark
| | - D J Leeming
- Nordic Bioscience, Biomarkers & Research A/S, Herlev, Denmark
| |
Collapse
|
9
|
Li H, Xiao Z, Quarles LD, Li W. Osteoporosis: Mechanism, Molecular Target and Current Status on Drug Development. Curr Med Chem 2021; 28:1489-1507. [PMID: 32223730 PMCID: PMC7665836 DOI: 10.2174/0929867327666200330142432] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 11/22/2022]
Abstract
CDATA[Osteoporosis is a pathological loss of bone mass due to an imbalance in bone remodeling where osteoclast-mediated bone resorption exceeds osteoblast-mediated bone formation resulting in skeletal fragility and fractures. Anti-resorptive agents, such as bisphosphonates and SERMs, and anabolic drugs that stimulate bone formation, including PTH analogues and sclerostin inhibitors, are current treatments for osteoporosis. Despite their efficacy, severe side effects and loss of potency may limit the long term usage of a single drug. Sequential and combinational use of current drugs, such as switching from an anabolic to an anti-resorptive agent, may provide an alternative approach. Moreover, there are novel drugs being developed against emerging new targets such as Cathepsin K and 17β-HSD2 that may have less side effects. This review will summarize the molecular mechanisms of osteoporosis, current drugs for osteoporosis treatment, and new drug development strategies.
Collapse
Affiliation(s)
- Hanxuan Li
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, TN, 38163, USA
| | - Zhousheng Xiao
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, 38165, USA
| | - L. Darryl Quarles
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, 38165, USA
| | - Wei Li
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, TN, 38163, USA
| |
Collapse
|
10
|
Dell'Aquila E, Armento G, Iuliani M, Simonetti S, D'Onofrio L, Zeppola T, Madaudo C, Russano M, Citarella F, Ribelli G, Pantano F, Vincenzi B, Tonini G, Santini D. Denosumab for cancer-related bone loss. Expert Opin Biol Ther 2020; 20:1261-1274. [PMID: 32835531 DOI: 10.1080/14712598.2020.1814731] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Prolonged use of anti-cancer treatments in breast and prostate tumors alters physiological bone turnover leading to adverse skeletal related events, such as osteoporosis, loss of bone mass, and increased risk of fractures. These complications known as cancer treatment-induced bone loss (CTIBL) should be managed with bone targeting agents such as the bisphosphonates and denosumab. The latter is a monoclonal antibody against the receptor activator of nuclear factor-kB ligand (RANKL) that suppresses osteoclasts function and survival increasing bone mass. AREAS COVERED This review will focus on the mechanisms associated with bone loss induced by cancer treatments and the most recent evidence about the use of denosumab as preventive and therapeutic strategy to protect bone health. Moreover, we will discuss several key aspects regarding the clinical practical use of denosumab to optimize the management of CTLIB in breast and prostate cancer. EXPERT OPINION Denosumab treatment strongly prevents cancer therapies-related skeletal issues in breast and prostate cancer with a good safety profile. Adjuvant six-monthly denosumab delays the time to first fracture onset in early stage breast cancer patients with normal or altered bone mineral density (BMD). Similarly, denosumab treatment is able to prevent fractures and BMD loss in nonmetastatic prostate cancer patients.
Collapse
Affiliation(s)
| | - Grazia Armento
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Michele Iuliani
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Sonia Simonetti
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Loretta D'Onofrio
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Tea Zeppola
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Cristina Madaudo
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Marco Russano
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Fabrizio Citarella
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Giulia Ribelli
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Francesco Pantano
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Bruno Vincenzi
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Giuseppe Tonini
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Daniele Santini
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| |
Collapse
|
11
|
Room for improvement in reporting of trials discontinuing long-term medication: a systematic review. J Clin Epidemiol 2020; 119:65-74. [DOI: 10.1016/j.jclinepi.2019.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 09/20/2019] [Accepted: 11/19/2019] [Indexed: 12/23/2022]
|
12
|
Effects of discontinuation of chronic medication in primary care: a systematic review of deprescribing trials. Br J Gen Pract 2019; 68:e663-e672. [PMID: 30249607 DOI: 10.3399/bjgp18x699041] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 08/20/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Polypharmacy is becoming more prevalent and evaluation of appropriateness of medication use is increasingly important. The primary care physician often conducts the deprescribing process; however, there are several barriers to implementing this. AIM To examine the feasibility and safety of discontinuation of medication, with a focus on studies that have been conducted in the community, that is, primary care (or general practice) and nursing homes. DESIGN AND SETTING This systematic review included randomised controlled trials published in 2005-2017, which studied withdrawal of long-term drugs prescribed in primary care settings and compared continuing medication with discontinuing. METHOD PubMed and EMBASE searches were conducted and the extracted data included the number of patients who successfully stopped medication and the number of patients who experienced relapse of symptoms or restarted medication. RESULTS A total of 27 studies reported in 26 papers were included in this review. The number of participants in the studies varied from 20 to 2471 and the mean age of participants ranged from 50.3 years to 89.2 years. The proportion of patients who successfully stopped their medication varied from 20% to 100%, and the range of reported relapse varied from 1.9% to 80%. CONCLUSION Only a few studies have examined the success rate and safety of discontinuing medication in primary care, and these studies are very heterogeneous. Most studies show that deprescribing and cessation of long-term use seem safe; however, there is a risk of relapse of symptoms. More research is needed to advise physicians in making evidence-based decisions about deprescribing in primary care settings.
Collapse
|
13
|
Guañabens N, Moro-Álvarez MJ, Casado E, Blanch-Rubió J, Gómez-Alonso C, Díaz-Guerra GM, Del Pino-Montes J, Valero Díaz de Lamadrid C, Peris P, Muñoz-Torres M. The next step after anti-osteoporotic drug discontinuation: an up-to-date review of sequential treatment. Endocrine 2019; 64:441-455. [PMID: 30963388 DOI: 10.1007/s12020-019-01919-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 03/29/2019] [Indexed: 12/16/2022]
Abstract
Several antiresorptive drugs, like bisphosphonates and denosumab, are currently available for the treatment of osteoporosis due to their evidenced efficacy in reducing fracture risk at mid-term. Osteoanabolic therapies, like teriparatide, whose treatment duration is limited to 2 years, have also shown efficacy in the reduction of fracture risk. However, depending on the severity of osteoporosis and the presence of other associated risk factors for fracture, some patients may require long-term treatment to preserve optimal bone strength and minimize bone fracture risk. Given the limited duration of some treatments, the fact that most of the antiresorptive drugs have not been assessed beyond 10 years, and the known long-term safety issues of these drugs, including atypical femoral fractures or osteonecrosis of the jaw, the long-term management of these patients may require an approach based on drug discontinuation and/or switching. In this regard, interest in sequential osteoporosis therapy, wherein drugs are initiated and discontinued over time, has grown in recent years, although the establishment of an optimal and individualized order of therapies remains controversial. This review reports the currently available clinical evidence on the discontinuation effects of different anti-osteoporotic drugs, as well as the clinical outcomes of the different sequential treatment regimens. The objective of this article is to present up-to-date practical knowledge on this area in order to provide guidance to the clinicians involved in the management of patients with osteoporosis.
Collapse
Affiliation(s)
- Núria Guañabens
- Metabolic Bone Diseases Unit, Department of Rheumatology, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Barcelona, Spain.
| | | | - Enrique Casado
- Rheumatology Department, Parc Taulí University Hospital, Autonomous University of Barcelona, Sabadell, Spain
| | | | - Carlos Gómez-Alonso
- Bone and Mineral Metabolism Unit, Central University Hospital of Asturias (HUCA), University of Oviedo, Oviedo, Spain
| | | | | | - Carmen Valero Díaz de Lamadrid
- University Hospital Marqués de Valdecilla, Research Institute Marqués de Valdecilla (IDIVAL), University of Cantabria, Santander, Spain
| | - Pilar Peris
- Metabolic Bone Diseases Unit, Department of Rheumatology, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Barcelona, Spain
| | - Manuel Muñoz-Torres
- Endocrinology and Nutrition Unit, Hospital Universitario San Cecilio de Granada, Department of Medicine, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria (Ibs.GRANADA), CIBERFES, Instituto de Salud Carlos III, Granada, Spain
| |
Collapse
|
14
|
Tsourdi E, Zillikens MC. Certainties and Uncertainties About Denosumab Discontinuation. Calcif Tissue Int 2018; 103:1-4. [PMID: 29926143 DOI: 10.1007/s00223-018-0436-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 05/25/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Elena Tsourdi
- Division of Endocrinology, Diabetes and Metabolic Bone Diseases, Department of Medicine III, Technische Universität Dresden Medical Center, Fetscherstraße 74, 01307, Dresden, Germany.
- Center for Healthy Aging, Technische Universität Dresden Medical Center, Dresden, Germany.
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| |
Collapse
|
15
|
Tsourdi E, Langdahl B, Cohen-Solal M, Aubry-Rozier B, Eriksen EF, Guañabens N, Obermayer-Pietsch B, Ralston SH, Eastell R, Zillikens MC. Discontinuation of Denosumab therapy for osteoporosis: A systematic review and position statement by ECTS. Bone 2017; 105:11-17. [PMID: 28789921 DOI: 10.1016/j.bone.2017.08.003] [Citation(s) in RCA: 297] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 08/04/2017] [Accepted: 08/04/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The optimal duration of osteoporosis treatment is controversial. As opposed to bisphosphonates, denosumab does not incorporate into bone matrix and bone turnover is not suppressed after its cessation. Recent reports imply that denosumab discontinuation may lead to an increased risk of multiple vertebral fractures. METHODS The European Calcified Tissue Society (ECTS) formed a working group to perform a systematic review of existing literature on the effects of stopping denosumab and provide advice on management. RESULTS Data from phase 2 and 3 clinical trials underscore a rapid decrease of bone mineral density (BMD) and a steep increase in bone turnover markers (BTMs) after discontinuation of denosumab. Clinical case series report multiple vertebral fractures after discontinuation of denosumab and a renewed analysis of FREEDOM and FREEDOM Extension Trial suggests, albeit does not prove, that the risk of multiple vertebral fractures may be increased when denosumab is stopped due to a rebound increase in bone resorption. CONCLUSION There appears to be an increased risk of multiple vertebral fractures after discontinuation of denosumab although strong evidence for such an effect and for measures to prevent the occurring bone loss is lacking. Clinicians and patients should be aware of this potential risk. Based on available data, a re-evaluation should be performed after 5years of denosumab treatment. Patients considered at high fracture risk should either continue denosumab therapy for up to 10years or be switched to an alternative treatment. For patients at low risk, a decision to discontinue denosumab could be made after 5years, but bisphosphonate therapy should be considered to reduce or prevent the rebound increase in bone turnover. However, since the optimal bisphosphonate regimen post-denosumab is currently unknown continuation of denosumab can also be considered until results from ongoing trials become available. Based on current data, denosumab should not be stopped without considering alternative treatment in order to prevent rapid BMD loss and a potential rebound in vertebral fracture risk.
Collapse
Affiliation(s)
- Elena Tsourdi
- Department of Medicine III, Technische Universität Dresden, Dresden, Germany; Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
| | - Bente Langdahl
- Medical Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark
| | - Martine Cohen-Solal
- Inserm U1132 and University Paris-Diderot, Department of Rheumatology, Lariboisière Hospital, Paris, France
| | | | - Erik Fink Eriksen
- Department of Clinical Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Nuria Guañabens
- Department of Rheumatology, Metabolic Bone Diseases Unit, Hospital Clínic, Barcelona, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Barbara Obermayer-Pietsch
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University Graz, Austria; Center for Biomarker Research in Medicine (CBmed), Graz, Austria
| | - Stuart H Ralston
- Centre for Genomic and Experimental Medicine, MRC Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Richard Eastell
- Mellanby Centre for Bone Research, University of Sheffield, UK
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands.
| |
Collapse
|
16
|
Naylor KE, Jacques RM, Peel NFA, Gossiel F, Eastell R. Response of bone turnover markers to raloxifene treatment in postmenopausal women with osteopenia. Osteoporos Int 2016; 27:2585-92. [PMID: 27026335 DOI: 10.1007/s00198-016-3573-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 03/14/2016] [Indexed: 10/22/2022]
Abstract
UNLABELLED We used two methods of identifying women who reached the target for raloxifene treatment with bone turnover markers. Both approaches identified women that responded to treatment but did not fully agree and may be complementary. INTRODUCTION The change in bone turnover markers (BTMs) in response to osteoporosis therapy can be assessed by a decrease beyond the least significant change (LSC) or below the mean of the reference interval (RI). We compared the performance of these two approaches in women treated with raloxifene. METHODS Fifty postmenopausal osteopenic women (age 51-72 years) were randomised to raloxifene or no treatment for 2 years. Blood samples were collected for the measurement of BTM. The LSC for each marker was calculated from the untreated women and the RI obtained from healthy premenopausal women (age 35-40 years). Bone mineral density (BMD) was measured at the spine and hip. RESULTS There was a decrease in BTM in response to raloxifene treatment, percentage change at 12 weeks: C terminal telopeptide of type I collagen (CTX) -39 % (95 % CI -48 to -28) and N terminal propeptide of type I procollagen (PINP) -32 % (95 % CI -40 to -23) P < 0.001. The proportion of women classified as responding to treatment using LSC at 12 weeks was as follows: CTX 38 % and PINP 52 % and at 48 weeks CTX 60 % and PINP 65 %. For the RI approach, the proportion of women classified as responding to treatment at 12 weeks was CTX and PINP 38 % and at 48 weeks CTX 40 % and PINP 45 %. There was a significant difference in the change in spine BMD in the raloxifene-treated group compared to the no-treatment group at week 48: difference 0.031 g/cm(2) (95 % CI 0.016 to 0.046, P < 0.001). CONCLUSIONS The two approaches identified women that reached the target for treatment using BTM. Both LSC and RI criteria appear useful in identifying treatment response, but the two approaches do not fully overlap and may be complementary.
Collapse
Affiliation(s)
- K E Naylor
- Academic Unit of Bone Metabolism, The Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK.
| | - R M Jacques
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - N F A Peel
- Metabolic Bone Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital Sheffield, Sheffield, UK
| | - F Gossiel
- Academic Unit of Bone Metabolism, The Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - R Eastell
- Academic Unit of Bone Metabolism, The Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| |
Collapse
|
17
|
Adler RA, El-Hajj Fuleihan G, Bauer DC, Camacho PM, Clarke BL, Clines GA, Compston JE, Drake MT, Edwards BJ, Favus MJ, Greenspan SL, McKinney R, Pignolo RJ, Sellmeyer DE. Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment: Report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res 2016; 31:16-35. [PMID: 26350171 PMCID: PMC4906542 DOI: 10.1002/jbmr.2708] [Citation(s) in RCA: 365] [Impact Index Per Article: 45.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 09/04/2015] [Accepted: 09/07/2015] [Indexed: 12/19/2022]
Abstract
Bisphosphonates (BPs) are the most commonly used medications for osteoporosis. This ASBMR report provides guidance on BP therapy duration with a risk-benefit perspective. Two trials provided evidence for long-term BP use. In the Fracture Intervention Trial Long-term Extension (FLEX), postmenopausal women receiving alendronate for 10 years had fewer clinical vertebral fractures than those switched to placebo after 5 years. In the HORIZON extension, women who received 6 annual infusions of zoledronic acid had fewer morphometric vertebral fractures compared with those switched to placebo after 3 years. Low hip T-score, between -2 and -2.5 in FLEX and below -2.5 in HORIZON extension, predicted a beneficial response to continued therapy. Hence, the Task Force suggests that after 5 years of oral BP or 3 years of intravenous BP, reassessment of risk should be considered. In women at high risk, for example, older women, those with a low hip T-score or high fracture risk score, those with previous major osteoporotic fracture, or who fracture on therapy, continuation of treatment for up to 10 years (oral) or 6 years (intravenous), with periodic evaluation, should be considered. The risk of atypical femoral fracture, but not osteonecrosis of the jaw, clearly increases with BP therapy duration, but such rare events are outweighed by vertebral fracture risk reduction in high-risk patients. For women not at high fracture risk after 3 to 5 years of BP treatment, a drug holiday of 2 to 3 years can be considered. The suggested approach for long-term BP use is based on limited evidence, only for vertebral fracture reduction, in mostly white postmenopausal women, and does not replace the need for clinical judgment. It may be applicable to men and patients with glucocorticoid-induced osteoporosis, with some adaptations. It is unlikely that future trials will provide data for formulating definitive recommendations. © 2015 American Society for Bone and Mineral Research.
Collapse
Affiliation(s)
- Robert A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | | | - Douglas C Bauer
- University of California, San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Henriksen K, Christiansen C, Karsdal MA. Role of biochemical markers in the management of osteoporosis. Climacteric 2015; 18 Suppl 2:10-8. [DOI: 10.3109/13697137.2015.1101256] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
19
|
Adami S, Idolazzi L, Fracassi E, Gatti D, Rossini M. Osteoporosis Treatment: When to Discontinue and When to Re-start. Bone Res 2013; 1:323-35. [PMID: 26273510 DOI: 10.4248/br201304003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 10/05/2013] [Indexed: 11/10/2022] Open
Abstract
A number of effective therapies for the treatment of osteoporosis have become available in recent years. However, uncertainty exists regarding their long-term use and effectiveness. Bisphosphonate treatment, unlike hormone replacement, denosumab or teriparatide, is associated with benefits extended even after treatment discontinuation. The extended benefits are most apparent for alendronate (ALN) and zoledronate (ZOL). A drug holiday might be considered in patients at low-moderate risk and who have been fully compliant with treatment, and who have had a response to treatment. In patients at low-moderate risk of fractures the decision to consider a drug holiday should be balanced also with the safety profile of each treatment.
Collapse
Affiliation(s)
- Silvano Adami
- Rheumatology Unit, University of Verona , 37126 Verona, Italy
| | - Luca Idolazzi
- Rheumatology Unit, University of Verona , 37126 Verona, Italy
| | - Elena Fracassi
- Rheumatology Unit, University of Verona , 37126 Verona, Italy
| | - Davide Gatti
- Rheumatology Unit, University of Verona , 37126 Verona, Italy
| | | |
Collapse
|
20
|
Finigan J, Naylor K, Paggiosi MA, Peel NF, Eastell R. Adherence to raloxifene therapy: assessment methods and relationship with efficacy. Osteoporos Int 2013; 24:2879-86. [PMID: 23695420 DOI: 10.1007/s00198-013-2386-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 04/22/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED Response to therapy depends on patient compliance but accurate assessment is difficult and adequate levels of adherence are uncertain. Adherence to raloxifene treatment may be assessed more accurately by electronic monitoring than by counting returned tablets. The level of adherence is positively associated with the degree of bone response. INTRODUCTION Adherence to study medication is usually estimated by counting returned tablets. This method relies on subjects' honesty and may be inaccurate. We aimed to assess adherence more accurately, and examine its effect on measures of bone response, by using electronic monitoring. METHODS Osteopenic women, ages 50 to 80, were prescribed daily raloxifene for 2 years. Electronic bottle caps (Medication Event Monitoring System (MEMS), Aardex) recorded the date and time on opening. Returned tablets were also counted. We measured bone mineral density (BMD) in duplicate at the spine and hip at baseline and 2 years. We also measured urinary N-terminal cross-linked telopeptide of type I collagen (NTX) at baseline, 1 and 2 years. We calculated the percentage changes in BMD and NTX from mean baseline to mean follow up measurements. Percentage adherence was assessed by both methods for 71 subjects that completed the study. RESULTS The two methods correlated significantly (p <0.001, Spearman's rho = 0.73) but the tablet count showed a higher median adherence than the MEMS caps (95.7 vs. 85.0%, p <0.001), with greater divergence at lower adherence levels. MEMS adherence in 65 subjects with complete data correlated with NTX response (p <0.01, rho = -0.33) but with BMD response only at the femoral neck. However, adherence in the lowest quartile was associated with poorer BMD response at all sites (p <0.05). CONCLUSION Tablet counts may give similar results overall but conceal substantial individual non-adherence. Monitoring caps may assess adherence more accurately than tablet counts and would be the preferred method in clinical trials. The degree of adherence is associated with both bone turnover and BMD responses to anti-resorptive therapy.
Collapse
Affiliation(s)
- J Finigan
- Academic Unit of Bone Metabolism, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK,
| | | | | | | | | |
Collapse
|
21
|
Yoh K, Hamaya E, Urushihara H, Iikuni N, Yamamoto T, Taketsuna M, Miyauchi A, Sowa H, Tanaka K. Quality of life in raloxifene-treated Japanese women with postmenopausal osteoporosis: a prospective, postmarketing observational study. Curr Med Res Opin 2012; 28:1757-66. [PMID: 23035693 DOI: 10.1185/03007995.2012.736860] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess changes in quality of life (QOL) and pain in raloxifene-treated Japanese women with postmenopausal osteoporosis. RESEARCH DESIGN AND METHODS This prospective, postmarketing observational study was conducted at 60 Japanese hospitals from September 2007 to February 2009 and included Japanese women with postmenopausal osteoporosis who were new to standard treatment with raloxifene (60 mg/day). Primary outcome measures (QOL and pain) were assessed using the Short Form-8 (SF-8), European Quality of Life Instrument (EQ-5D), osteoporosis-specific Japanese Osteoporosis Quality of Life Questionnaire (JOQOL), a visual analogue scale (VAS-pain), and a pain frequency survey. Assessments were performed at baseline and 8 (except JOQOL) and 24 weeks after first administration of raloxifene. Adverse drug reactions were recorded. Japan Pharmaceutical Information Center registration number: JapicCTI-070465. RESULTS A total of 506 participants, mean (±standard deviation [SD]) age = 70.7 ± 8.7 years, completed ≥1 follow-up assessment and were included in the analyses. All QOL scores increased from baseline during follow-up. All SF-8 domain scores increased significantly from baseline after 8 and 24 weeks (P < 0.001). Mean (±SD) EQ-5D scores increased significantly from baseline (0.70 ± 0.17) by 0.05 ± 0.15 after 8 weeks and 0.07 ± 0.17 after 24 weeks (P < 0.001). The mean (±SD) total JOQOL score increased significantly from baseline (66.8 ± 16.5) by 3.8 ± 11.3 after 24 weeks (P < 0.001). The percentage of participants with a ≥20 mm reduction in VAS-pain was 32.6% (120/368) and 39.5% (115/291) after 8 and 24 weeks, respectively. The frequency of pain reported by participants decreased after 8 and 24 weeks. Forty adverse drug reactions were reported by 34 participants. LIMITATIONS Limitations include the lack of a control group, the possibility of the changes being due to the natural disease course, and potential selection bias. CONCLUSIONS Our findings suggest that standard treatment with raloxifene improves QOL and relieves pain in Japanese women with postmenopausal osteoporosis in a real-world clinical setting.
Collapse
Affiliation(s)
- Kousei Yoh
- Department of Orthopedic Surgery, Sasayama Hospital, Hyogo College of Medicine, Sasayama, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
Biochemical markers of bone turnover (bone turnover markers, BTMs) can be used to study changes in bone remodelling in osteoporosis. Investigators and clinicians should be aware of the appropriate sample collection and storage conditions for optimum measurements of these markers. Improvements in the variability of BTM measurements have resulted from the development of assays for automated analysers, and from international consensus regarding their use. Appropriate reference intervals should be used for the optimum interpretation of results. BTMs can provide information that is useful for the management of patients with osteoporosis, for both the initial clinical assessment and for guiding and monitoring of treatment. BTMs are clinically useful to determine possible causes of secondary osteoporosis by identifying patients with high bone turnover and rapid bone loss. In the follow-up of treatment response, BTM levels respond rapidly to both anabolic and antiresorptive treatments. BTM changes can also be used for understanding the mechanism of action of drugs in development and identifying the correct dose; they are also potentially useful as surrogate biomarkers for fracture.
Collapse
|
23
|
Henriksen K, Leeming DJ, Christiansen C, Karsdal MA. Use of Bone Turnover Markers in Clinical Osteoporosis Assessment in Women: Current Issues and Future Options. WOMENS HEALTH 2011; 7:689-98. [DOI: 10.2217/whe.11.74] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Monitoring bone turnover of the adult and aging skeleton is essential for optimal treatment of bone metabolic diseases, such as postmenopausal osteoporosis. Diagnosis of osteoporosis is based solely on dual-emission x-ray absorptiometry-based measurements of bone mineral density. However, within the last 20 years, biochemical markers of bone turnover have been implemented to a larger degree, and especially within the field of drug development. Numerous clinical studies have underscored that the markers have promise in terms of predicting patients at high risk of losing bone, future fracture events and importantly also the fracture efficacy of drugs in development. Furthermore, while classical methods often require years to monitor the changes, the bone turnover markers do so within a shorter time span. The aims of this article are to provide an update on the different biochemical markers of bone turnover, and to give an overview of their applications in epidemiological and clinical research especially in women. The main emphasis will be on their utility in clinical trials testing the efficacy of drugs for the treatment of osteoporosis, and their ability to supplement bone mass measurements. Finally, recent evidence suggests that biochemical markers may provide information on bone age that may indirectly relate to bone quality, and this is discussed together with future possibilities for measuring bone quality using bone turnover markers. In summary, a more targeted use of biomarkers could assist in the identification of high-risk patients, the process of drug discovery and monitoring of the efficacy of osteoporosis treatment in clinical settings.
Collapse
Affiliation(s)
- K Henriksen
- Department of Bone Biology & Biomarkers, Nordic Bioscience A/S, Herlev Hovedgade 207, DK-2730 Herlev, Denmark
| | - DJ Leeming
- Department of Bone Biology & Biomarkers, Nordic Bioscience A/S, Herlev Hovedgade 207, DK-2730 Herlev, Denmark
| | - C Christiansen
- Department of Bone Biology & Biomarkers, Nordic Bioscience A/S, Herlev Hovedgade 207, DK-2730 Herlev, Denmark
| | - MA Karsdal
- Department of Bone Biology & Biomarkers, Nordic Bioscience A/S, Herlev Hovedgade 207, DK-2730 Herlev, Denmark
| |
Collapse
|
24
|
Laster AJ, Tanner SB. Duration of treatment in postmenopausal osteoporosis: how long to treat and what are the consequences of cessation of treatment? Rheum Dis Clin North Am 2011; 37:323-36, v. [PMID: 22023894 DOI: 10.1016/j.rdc.2011.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Although a variety of medications are effective for the treatment of postmenopausal osteoporosis, there is concern that long-term use may incur side effects. Consequently, some have proposed discontinuing or temporarily suspending treatment after a defined period of time. As the benefits of fracture risk reduction may recede during this "drug holiday", the clinician may be faced with deciding when to resume therapy (and with which agent) while avoiding the possible cumulative risk of side effects. This article summarizes data regarding length of treatment and the effects of cessation of treatment on bone density, bone turnover markers, and fracture risk.
Collapse
Affiliation(s)
- Andrew J Laster
- Arthritis & Osteoporosis Consultants of the Carolinas, 1918 Randolph Road, Suite 600, Charlotte, NC 28207, USA
| | | |
Collapse
|
25
|
Vasikaran S, Eastell R, Bruyère O, Foldes AJ, Garnero P, Griesmacher A, McClung M, Morris HA, Silverman S, Trenti T, Wahl DA, Cooper C, Kanis JA. Markers of bone turnover for the prediction of fracture risk and monitoring of osteoporosis treatment: a need for international reference standards. Osteoporos Int 2011; 22:391-420. [PMID: 21184054 DOI: 10.1007/s00198-010-1501-1] [Citation(s) in RCA: 704] [Impact Index Per Article: 54.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Accepted: 11/09/2010] [Indexed: 02/06/2023]
Abstract
UNLABELLED The International Osteoporosis Foundation (IOF) and the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) recommend that a marker of bone formation (serum procollagen type I N propeptide, s-PINP) and a marker of bone resorption (serum C-terminal telopeptide of type I collagen, s-CTX) are used as reference analytes for bone turnover markers in clinical studies. INTRODUCTION Bone turnover markers (BTM) predict fracture risk, and treatment-induced changes in specific markers account for a substantial proportion of fracture risk reduction. The aims of this report were to determine their clinical potential in the prediction of fracture risk and for monitoring the treatment of osteoporosis and to set an appropriate research agenda. METHODS Evidence from prospective studies was gathered through literature review of the PUBMED database between the years 2000 and 2010 and the systematic review of the Agency for Healthcare Research and Quality up to 2001. RESULTS High levels of BTMs may predict fracture risk independently from bone mineral density in postmenopausal women. They have been used for this purpose in clinical practice for many years, but there is still a need for stronger evidence on which to base practice. BTMs provide pharmacodynamic information on the response to osteoporosis treatment, and as a result, they are widely used for monitoring treatment in the individual. However, their clinical value for monitoring is limited by inadequate appreciation of the sources of variability, by limited data for comparison of treatments using the same BTM and by inadequate quality control. IOF/IFCC recommend one bone formation marker (s-PINP) and one bone resorption marker (s-CTX) to be used as reference markers and measured by standardised assays in observational and intervention studies in order to compare the performance of alternatives and to enlarge the international experience of the application of markers to clinical medicine. CONCLUSION BTM hold promise in fracture risk prediction and for monitoring treatment. Uncertainties over their clinical use can be in part resolved by adopting international reference standards.
Collapse
Affiliation(s)
- S Vasikaran
- Department of Core Clinical Pathology and Biochemistry, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, WA, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Paggiosi MA, Clowes JA, Finigan J, Naylor KE, Peel NFA, Eastell R. Performance of quantitative ultrasound measurements of bone for monitoring raloxifene therapy. J Clin Densitom 2010; 13:441-50. [PMID: 20850365 DOI: 10.1016/j.jocd.2010.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 06/28/2010] [Accepted: 06/29/2010] [Indexed: 11/30/2022]
Abstract
Raloxifene increases bone mineral density (BMD) and decreases vertebral fracture risk; the effects on quantitative ultrasound (QUS) variables, however, have been less well studied. We aimed to further evaluate the effectiveness of QUS for monitoring raloxifene treatment and withdrawal effects. Osteopenic, postmenopausal women (age=50-80 yr, n=125), who completed a 96-wk study (phase A) evaluating treatment compliance or monitoring, were invited to participate in a 96-wk raloxifene withdrawal study (phase B). Those originally receiving treatment were then randomized to continue on raloxifene (60 mg/d)+calcium (500 mg/d) (n=23) or to discontinue raloxifene and take placebo+calcium (500 mg/d) (n=23). Previously untreated women remained untreated (n=12). Yearly QUS and BMD measurements were performed. At the end of phase A, lumbar spine BMD (p=0.005), amplitude-dependent speed of sound (Ad-SoS) (p=0.006) and average SoS (p=0.040) decreased in untreated women but remained stable in treated women. Significant changes in Ad-SoS and ultrasonic bone profiler index had occurred in treated women by the end of phase B (p<0.01). All variables, except bone transmission time, were higher for those receiving any raloxifene treatment (p<0.05). Until further knowledge has been acquired, QUS measurement variables should only be used in conjunction with BMD when assessing changes in bone because of raloxifene therapy.
Collapse
Affiliation(s)
- Margaret A Paggiosi
- Sheffield NIHR Bone Biomedical Research Unit, Centre for Biomedical Research, Northern General Hospital, Sheffield, UK
| | | | | | | | | | | |
Collapse
|