Very high frequency of fragility fractures associated with high-dose glucocorticoids in postmenopausal women: A retrospective study

An Update on the Fracture Risk Assessment Tool: What Have We Learned over 15+ years?

The Fracture Risk Assessment Tool (FRAX) was launched in 2008 and uses clinical variables to estimate 10-year fracture risk. FRAX has been incorporated into clinical treatment guidelines and is well validated in specific disease states like chronic kidney disease. However, there are risk factors which are not captured by FRAX such as diabetes and falls. The use of race-ethnicity as a factor in FRAX is a source of controversy. Though other risk calculators exist, FRAX is likely to remain the gold standard for fracture risk prediction. An update of FRAX using data from a larger cohort is in development.

Prevention and treatment of glucocorticoid-induced osteoporosis in adults: recommendations from the European Calcified Tissue Society

INTRODUCTION

This report presents the recommendations of the European Calcified Tissue Society (ECTS) for the prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) in adults. Our starting point was that the recommendations be evidence based, focused on non-bone specialists who treat patients with glucocorticoid (GC) and broadly supported by ECTS.

METHODS

The recommendations were developed by global experts. After a comprehensive review of the literature, 25 recommendations were formulated, based on quality evidence. For stratifying fracture risk and the most appropriate first line of treatment, we have classified patients into 3 categories: those at medium risk of fractures, ie, adults without a recent (in the last 2 years) history of fracture; those at high risk of fractures, ie, adults with recent history of fracture, and/or at least one vertebral fracture (grade ≥ 2 according to Genant classification); and those at very high risk of fractures, ie, adults aged ≥70 years with a recent hip fracture, pelvis fracture, and/or at least one vertebral fracture (grade ≥ 2 according to Genant classification). The subtopics in the recommendations include who to assess, how to assess, who to treat, how to treat, and follow-up and monitoring.

RESULTS

General measures are recommended for all patients who are being prescribed GCs for ≥3 months, ie, calcium and protein intake should be normalized, a 25(OH) vitamin D concentration of 50-125 nmol/L should be attained, and the risk of falls be minimized. (1) Who to assess? (R1-2) A preliminary assessment of fracture risk should be routinely performed in patients likely to receive oral GCs for ≥3 months: (i) women and men ≥ 50 years and (ii) patients at increased risk of fracture (history of fragility fracture and/or have comorbidities or are on medications that are frequently associated with osteoporosis. (2) How to assess (fracture risk)? (R3-6) Clinical risk factors include history of fragility fracture, systematic vertebral imaging, and GC dose-adjusted FRAX, measurement of bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), fall risk, and biochemical testing. (3) Who to treat? (R7-12) Anti-osteoporosis treatment is indicated for women and men ≥ 50 years with (i) the presence of a recent history of vertebral and/or non-vertebral fracture (less than 2 years), (ii) and/or a GC dosage ≥ 7.5 mg/day, (iii) and/or age ≥ 70 years, (iv) and/or a T-score ≤ -1.5, (v) and/or 10-year probability risk above the country specific GC dose-adjusted FRAX® thresholds. In premenopausal women and men < 50 years with a Z-score ≤ -2 and/or a history of fragility fracture, it is recommended to refer the patient to a bone specialist. (4) How to treat? (R13-18) In women and men ≥ 50 years, (i) alendronate or risedronate is preferred as the first line of treatment in patients at medium risk of fractures, (ii) zoledronic acid or denosumab in patients at high risk of fractures, and (iii) teriparatide in patients at very high risk of fractures. It is imperative that sequential therapy be implemented in individuals receiving denosumab or teriparatide as their first-line treatment regimen. (5) Follow-up and monitoring (R19-25): in patients receiving anti-osteoporosis treatment, monitoring of clinical risk factors (eg, history of fragility fracture), systematic vertebral imaging, fall risk, BMD measurement using DXA, and biochemical testing should be performed regularly during follow-up.

CONCLUSIONS

The new, evidence-based recommendations by the ECTS for the prevention and treatment of GIOP provide clear and pragmatic advice to all health practitioners especially those who are not bone specialists.

Insights and implications of sexual dimorphism in osteoporosis

Osteoporosis, a metabolic bone disease characterized by low bone mineral density and deterioration of bone microarchitecture, has led to a high risk of fatal osteoporotic fractures worldwide. Accumulating evidence has revealed that sexual dimorphism is a notable feature of osteoporosis, with sex-specific differences in epidemiology and pathogenesis. Specifically, females are more susceptible than males to osteoporosis, while males are more prone to disability or death from the disease. To date, sex chromosome abnormalities and steroid hormones have been proven to contribute greatly to sexual dimorphism in osteoporosis by regulating the functions of bone cells. Understanding the sex-specific differences in osteoporosis and its related complications is essential for improving treatment strategies tailored to women and men. This literature review focuses on the mechanisms underlying sexual dimorphism in osteoporosis, mainly in a population of aging patients, chronic glucocorticoid administration, and diabetes. Moreover, we highlight the implications of sexual dimorphism for developing therapeutics and preventive strategies and screening approaches tailored to women and men. Additionally, the challenges in translating bench research to bedside treatments and future directions to overcome these obstacles will be discussed.

Reliability of lateral wall-thickness measurement in trochanteric fractures and parameters associated with lateral wall integrity

Background

The AO Foundation/Orthopaedic Trauma Association (AO/OTA) introduced a new trochanteric fracture classification in January 2018, concerning the lateral wall integrity. It suggested the intramedullary nail fixation in patients with an incompetent lateral wall fracture.

Objective

To determine the reliability of lateral wall-thickness measurement and the fracture parameters associated with lateral wall integrity.

Methods

This retrospective study evaluated patients with an intertrochanteric fracture who had had surgery in King Chulalongkorn Memorial Hospital between January 2014 and January 2019. The lateral wall was measured by anteroposterior plain radiography by four raters, two times each. The demographic data and fracture parameters were assessed and compared with respect to lateral wall integrity.

Result

In a total of 236 femurs and 232 patients having the 2018 AO/OTA-specified 31A1 and 31A2 intertrochanteric fractures, the lateral wall-thickness measurement showed excellent inter-rater reliability at 0.944 (0.927-0.957) and good-to-excellent intra-rater reliability ranging from 0.835 to 0.972. The parameters associated with lateral wall incompetence as per the multivariate logistic regression analysis were fracture angle (odds ratio [OR] = 0.95), distal greater trochanter involvement (OR = 9.47), and fragments at the intertrochanter area (OR = 4.49) and at the lesser trochanter (OR = 2.6).

Conclusion

Some of the parameters related to trochanteric fractures are associated with lateral wall incompetence. Lateral wall-thickness measurement is a reproducible method, which has been suggested for use by the AO/OTA 2018 classification. It is easy to use and can help select the appropriate treatment for intertrochanteric fracture patients.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis: an update of Brazilian Society of Rheumatology (2020)

The Brazilian guidelines for prevention and treatment of glucocorticoid-induced osteoporosis were updated and important topics were included such as assessment of risk fracture using FRAX Brazil, use of denosumab, and also recommendations for the use of glucocorticoid pulse therapy and inhaled glucocortiocoid.

INTRODUCTION

Glucocorticoids (GCs) are used in almost all medical specialties and the incidences of vertebral/nonvertebral fractures range from 30 to 50% in individuals treated with GCs for over 3 months. Thus, osteoporosis and frailty fractures should be prevented and treated in patients initiating treatment or already being treated with GCs. The Committee for Osteoporosis and Bone Metabolic Disorders of the Brazilian Society of Rheumatology (BSR) established in 2012 the Brazilian Guidelines for glucocorticoid-induced osteoporosis (GIO). Herein, we provide a comprehensive update of the original guidelines based on improved available scientific evidence and/or expert experience.

METHODS

From March to June 2020, the Osteoporosis Committee of the BRS had meetings to update the questions presented in the first consensus (2012). Thus, twenty-six questions considered essential for the preparation of the recommendations were selected. A systematic literature review based on real-life scenarios was undertaken to answer the proposed questions. The MEDLINE, EMBASE, and SCOPUS databases were searched using specific search keywords.

RESULTS

Based on the review and expert opinion, the recommendations were updated for each of the 26 questions. We included 48 new bibliographic references that became available after the date of the publication of the first version of the consensus.

CONCLUSION

We updated the Brazilian guidelines for the prevention/treatment of GIO. New topics were added in this update, such as the assessment of risk fracture using FRAX Brazil, the use of denosumab, and approaches for the treatment of children and adolescents. Furthermore, we included recommendations for the use of inhaled GCs and GC pulse therapy in clinical settings.