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Ross JD, Diaz-Thomas A. Perioperative Evaluation and Management of Children with Osteoporosis and Low Bone Mineral Density. Orthop Clin North Am 2024; 55:345-353. [PMID: 38782506 DOI: 10.1016/j.ocl.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
As medical and surgical treatment options for children with osteoporosis expand, multidisciplinary strategies for bone health optimization become more important. Each patient's bone mineral density and fracture history should be interpreted in context. Off-label bisphosphonate use is a standard pharmacologic intervention for children with osteoporosis for optimal bone accrual. It is possible to continue this therapy perioperatively under certain circumstances. The rare side effects (osteonecrosis of the jaw and atypical femur fractures) seem less common in children. Physical therapy, vitamin D supplementation, and other interventions are also important tools for optimal bone health perioperatively and for satisfactory surgical outcomes.
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Affiliation(s)
- Jordan D Ross
- University of Tennessee Health Science Center, Faculty Office Building, Room 119, 49 North Dunlap, Memphis, TN 38103, USA.
| | - Alicia Diaz-Thomas
- Division of Pediatric Endocrinology, University of Tennessee Heath Science Center, Suite 1006, 910 Madison Avenue, Memphis, TN 38163, USA; Division of Pediatric Endocrinology, Le Bonheur Children's Hospital, Memphis, TN, USA
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Hirokawa T, Zukawa M, Makino H, Osada R, Kawaguchi Y. Therapeutic strategy for atypical ulnar fracture in long use of bisphosphonate: A systematic review. J Orthop Sci 2024; 29:880-884. [PMID: 37032267 DOI: 10.1016/j.jos.2023.03.009] [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: 09/05/2022] [Revised: 02/09/2023] [Accepted: 03/12/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Atypical fractures are caused by the combined effects of severe suppression of bone metabolism (SSBT) due to long-term bisphosphonate therapy and chronic repetitive bone microdamage. Atypical ulnar fractures (AUFs) due to SSBT are rare, and there is no standard treatment strategy for such fractures. The relevant literature was reviewed, and the treatment strategy for AUF is discussed. METHODS A systematic review was conducted. All studies on ulnar fractures in individuals with a history of bisphosphonate use were included, and the data were extracted and analyzed from the perspective of the therapeutic strategy. RESULTS Forty limbs of 35 patients were included. As for the treatment of AUF, 31 limbs were treated surgically, and conservative treatment with casting was performed for 9 limbs. The bone fusion rate was 22/40 (55.0%), and non-union was seen in all patients treated conservatively. There was a significant difference in the bone fusion rate between patients with surgical treatment and those with conservative treatment. The bone fusion rate of patients with parathyroid hormone (PTH) and surgery was 82.3% (14/17 limbs); the bone fusion rate with PTH and bone graft was 69.2% (9/13 limbs). However, there were no significant differences in the fusion rate in the groups with or without PTH, with or without bone grafting, or the combination of the two treatments. There was also no significant difference in the bone fusion rate in the groups with or without low-intensity pulsed ultrasound (LIPUS) treatment. CONCLUSIONS Based on the literature review, surgery is necessary to achieve bone union, but surgery alone is not adequate to achieve bony union. Bone grafting and the administration of PTH and LIPUS may promote early bone fusion, but the present study did not show significant advantages of these additional treatments for bone union.
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Affiliation(s)
- Tatsuro Hirokawa
- Department of Orthopaedic Surgery, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Mineyuki Zukawa
- Department of Orthopaedic Surgery, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Hiroto Makino
- Department of Orthopaedic Surgery, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Ryusuke Osada
- Department of Orthopaedic Surgery, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Yoshiharu Kawaguchi
- Department of Orthopaedic Surgery, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan.
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Lippuner K, Kyuchukova M, Schwab P, Rizzoli R. Differences in femoral fracture localizations in men and women in Switzerland between 1998 and 2021-reversal of the secular trend? Osteoporos Int 2024; 35:893-902. [PMID: 38396306 PMCID: PMC11031489 DOI: 10.1007/s00198-024-07016-5] [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: 08/28/2023] [Accepted: 12/28/2023] [Indexed: 02/25/2024]
Abstract
Number and age-standardized incidences of femoral fractures by sex and localization were determined annually between 1998 and 2021 in subjects aged 45 years or older living in Switzerland. The number and incidences of femoral neck, pertrochanteric, subtrochanteric, and femoral shaft fractures followed distinct unexpected trend patterns. INTRODUCTION Long-term incidence trends for femoral fractures by individual localizations are unknown. METHODS Annual absolute number of hospitalizations and median age at hospital admission between 1998 and 2021 were extracted from the medical database of the Swiss Federal Office of Statistics by sex and 10-year age groups for the following 10th International Classification of Diseases (ICD-10) codes: femoral neck (ICD-10 S72.0), pertrochanteric (S72.1), subtrochanteric (S72.2), and femoral shaft fractures (S72.3). Age-standardized incidence rates (ASI) and corresponding trends were calculated. RESULTS Over 24 years, the number of femoral neck fractures increased in men (+ 45%) but decreased in women (- 7%) with ASI significantly decreasing by 20% and 37% (p < 0.001 for trend for both), respectively. By contrast, the number of pertrochanteric fractures increased by 67% and 45% in men and women, respectively, corresponding to a horizontal ASI-trend in men (n.s.) and a modest significant decreasing ASI-trend in women (p < 0.001). The number of subtrochanteric fractures increased in both sexes with corresponding modest significant reductions in ASI-trends (p = 0.015 and 0.002, respectively). Femoral shaft fractures almost doubled in men (+ 71%) and doubled in women (+ 100%) with corresponding significant increases in ASI-trends (p = 0.001 and p < 0.001, respectively). Age at admission increased for all fracture localizations, more so in men than in women and more so for subtrochanteric and shaft fractures than for "typical" hip fractures. CONCLUSION Incidence changes of pertrochanteric fractures and femoral shaft fractures deserve increased attention, especially in men. Pooling diagnostic codes for defining hip fractures may hide differing patterns by localization and sex.
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Affiliation(s)
- Kurt Lippuner
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Mariya Kyuchukova
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Schwab
- Swiss Federal Statistical Office, Neuchâtel, Switzerland
| | - René Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Snyder PJ, Bauer DC, Ellenberg SS, Cauley JA, Buhr KA, Bhasin S, Miller MG, Khan NS, Li X, Nissen SE. Testosterone Treatment and Fractures in Men with Hypogonadism. N Engl J Med 2024; 390:203-211. [PMID: 38231621 DOI: 10.1056/nejmoa2308836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND Testosterone treatment in men with hypogonadism improves bone density and quality, but trials with a sufficiently large sample and a sufficiently long duration to determine the effect of testosterone on the incidence of fractures are needed. METHODS In a subtrial of a double-blind, randomized, placebo-controlled trial that assessed the cardiovascular safety of testosterone treatment in middle-aged and older men with hypogonadism, we examined the risk of clinical fracture in a time-to-event analysis. Eligible men were 45 to 80 years of age with preexisting, or high risk of, cardiovascular disease; one or more symptoms of hypogonadism; and two morning testosterone concentrations of less than 300 ng per deciliter (10.4 nmol per liter), in fasting plasma samples obtained at least 48 hours apart. Participants were randomly assigned to apply a testosterone or placebo gel daily. At every visit, participants were asked if they had had a fracture since the previous visit. If they had, medical records were obtained and adjudicated. RESULTS The full-analysis population included 5204 participants (2601 in the testosterone group and 2603 in the placebo group). After a median follow-up of 3.19 years, a clinical fracture had occurred in 91 participants (3.50%) in the testosterone group and 64 participants (2.46%) in the placebo group (hazard ratio, 1.43; 95% confidence interval, 1.04 to 1.97). The fracture incidence also appeared to be higher in the testosterone group for all other fracture end points. CONCLUSIONS Among middle-aged and older men with hypogonadism, testosterone treatment did not result in a lower incidence of clinical fracture than placebo. The fracture incidence was numerically higher among men who received testosterone than among those who received placebo. (Funded by AbbVie and others; TRAVERSE ClinicalTrials.gov number, NCT03518034.).
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Affiliation(s)
- Peter J Snyder
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Douglas C Bauer
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Susan S Ellenberg
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Jane A Cauley
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Kevin A Buhr
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Shalender Bhasin
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Michael G Miller
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Nader S Khan
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Xue Li
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
| | - Steven E Nissen
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia (P.J.S., S.S.E.); the San Francisco Coordinating Center, University of California, San Francisco, San Francisco (D.C.B.); the University of Pittsburgh Graduate School of Public Health, Pittsburgh (J.A.C.); the University of Wisconsin Statistical Data Analysis Center, Madison (K.A.B.); Brigham and Women's Hospital, Harvard Medical School, Boston (S.B.); AbbVie, North Chicago, IL (M.G.M., N.S.K., X.L.); and the Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Cleveland (S.E.N.)
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Liu X, Makaroff KE, Almario CV, Khalil C, Choi SY, Curtis JR, Spiegel BMR. Determining patient preferences for the medical management of osteoporosis using conjoint analysis. Osteoporos Int 2024; 35:153-164. [PMID: 37721558 PMCID: PMC10787002 DOI: 10.1007/s00198-023-06882-9] [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: 02/22/2023] [Accepted: 07/31/2023] [Indexed: 09/19/2023]
Abstract
We used conjoint analysis-a method that assesses complex decision making-to quantify patients' choices when selecting an osteoporosis therapy. While 60% of people prioritized medication efficacy when deciding among treatments, the remaining 40% highly valued factors other than efficacy, suggesting the need for personalized shared decision-making tools. INTRODUCTION In this study, we aimed to examine patient decision-making surrounding osteoporosis medications using conjoint analysis. METHODS We enrolled osteoporosis patients at an academic medical center to complete an online conjoint exercise which calculated each patient's relative importance score of 6 osteoporosis medication attributes (higher = greater relative importance in decision-making). We used latent class analysis to identify distinct segments of patients with similar choice patterns and then used logistic regression to determine if demographics and osteoporosis disease features were associated with latent class assignment. RESULTS Overall, 304 participants completed the survey. The rank order of medication attributes by importance score was the following: efficacy at preventing hip fractures (accounted for 31.0% of decision making), mode of administration (17.5%); risk of serious side effects (16.6%); dose frequency (13.9%); efficacy at preventing spine fractures (12.5%); risk of non-serious side effects (8.4%). We found that 60.9% of the cohort prioritized medication efficacy as their top factor when selecting among the therapies. Being a college graduate, having stronger beliefs on the necessity of using medications for osteoporosis, and never having used osteoporosis medicines were the only factors associated with prioritizing medication efficacy for fracture prevention over the other factors in the decision-making process. CONCLUSIONS While about 60% of patients prioritized efficacy when selecting an osteoporosis therapy, the remaining 40% valued other factors more highly. Furthermore, individual patient characteristics and clinical factors did not reliably predict patient decision making, suggesting that development and implementation of shared decision-making tools is warranted.
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Affiliation(s)
- Xiaoyu Liu
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Katherine E Makaroff
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Christopher V Almario
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Carine Khalil
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - So Yung Choi
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Cancer, Los Angeles, CA, USA
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brennan M R Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA.
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Cyteval C, Szafors P, Pastor M. Brittle Bone Imaging: Diagnostic Procedures in Adults. Semin Musculoskelet Radiol 2023; 27:439-450. [PMID: 37748467 DOI: 10.1055/s-0043-1769776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
This article concentrates on generalized disorders causing bone fragility. The most frequent cause of brittle bone disease is osteoporosis, only diagnosed by elimination. First, malignant osteopathy must be ruled out: fracture on metastasis or multiple myeloma, which mimics osteoporosis when presenting as diffuse demineralization. Second, patients should be screened for signs of hyperparathyroidism or osteomalacia. Much more rarely, many other pathologies can lead to brittle bone by demineralization or associated increased bone density.The radiologist needs to know the clinical context and notably the patient's age (childhood or adulthood) at discovery, and known pathologies and ongoing or previous treatments: corticotherapy, bisphosphonates, denosumab, or prior radiotherapy in the affected region. Diagnostic hypotheses are guided by the type of demineralization and the presence of lytic, mixed, or densifying areas. Lastly, the aspect and location of fractures and association with other bone abnormalities refine the diagnosis.
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Ong TIW, Lim LL, Chan SP, Chee WSS, Ch’ng ASH, Chong EGM, Damodaran P, Hew FL, Ibrahim LB, Khor HM, Lai PSM, Lee JK, Lim AL, Lim BP, Paramasivam SS, Ratnasingam J, Siow YS, Tan ATB, Thiagarajan N, Yeap SS. A summary of the Malaysian Clinical Practice Guidelines on the management of postmenopausal osteoporosis, 2022. Osteoporos Sarcopenia 2023; 9:60-69. [PMID: 37496985 PMCID: PMC10366466 DOI: 10.1016/j.afos.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/01/2023] [Accepted: 06/04/2023] [Indexed: 07/28/2023] Open
Abstract
Objectives The aim of these Clinical Practice Guidelines is to provide evidence-based recommendations to assist healthcare providers in the screening, diagnosis and management of patients with postmenopausal osteoporosis (OP). Methods A list of key clinical questions on the assessment, diagnosis and treatment of OP was formulated. A literature search using the PubMed, Medline, Cochrane Databases of Systematic Reviews, and OVID electronic databases identified all relevant articles on OP based on the key clinical questions, from 2014 onwards, to update from the 2015 edition. The articles were graded using the SIGN50 format. For each statement, studies with the highest level of evidence were used to frame the recommendation. Results This article summarizes the diagnostic and treatment pathways for postmenopausal OP. Risk stratification of patients with OP encompasses clinical risk factors, bone mineral density measurements and FRAX risk estimates. Non-pharmacological measures including adequate calcium and vitamin D, regular exercise and falls prevention are recommended. Pharmacological measures depend on patients' fracture risk status. Very high-risk individuals are recommended for treatment with an anabolic agent, if available, followed by an anti-resorptive agent. Alternatively, parenteral anti-resorptive agents can be used. High-risk individuals should be treated with anti-resorptive agents. In low-risk individuals, menopausal hormone replacement or selective estrogen receptor modulators can be used, if indicated. Patients should be assessed regularly to monitor treatment response and treatment adjusted, as appropriate. Conclusions The pathways for the management of postmenopausal OP in Malaysia have been updated. Incorporation of fracture risk stratification can guide appropriate treatment.
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Affiliation(s)
- Terence Ing Wei Ong
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lee Ling Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Siew Pheng Chan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Subang Jaya Medical Centre, Subang Jaya, Selangor, Malaysia
| | | | | | | | | | - Fen Lee Hew
- Subang Jaya Medical Centre, Subang Jaya, Selangor, Malaysia
| | | | - Hui Min Khor
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Ai Lee Lim
- Hospital Pulau Pinang, Pulau Pinang, Malaysia
| | - Boon Ping Lim
- Subang Jaya Medical Centre, Subang Jaya, Selangor, Malaysia
| | | | - Jeyakantha Ratnasingam
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yew Siong Siow
- Subang Jaya Medical Centre, Subang Jaya, Selangor, Malaysia
| | | | | | - Swan Sim Yeap
- Subang Jaya Medical Centre, Subang Jaya, Selangor, Malaysia
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Sutton MM, Duffy MP, Verbruggen SW, Jacobs CR. Osteoclastogenesis Requires Primary Cilia Disassembly and Can Be Inhibited by Promoting Primary Cilia Formation Pharmacologically. Cells Tissues Organs 2023; 213:235-244. [PMID: 37231815 PMCID: PMC10863750 DOI: 10.1159/000531098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
The primary cilium is a solitary, sensory organelle with many roles in bone development, maintenance, and function. In the osteogenic cell lineage, including skeletal stem cells, osteoblasts, and osteocytes, the primary cilium plays a vital role in the regulation of bone formation, and this has made it a promising pharmaceutical target to maintain bone health. While the role of the primary cilium in the osteogenic cell lineage has been increasingly characterized, little is known about the potential impact of targeting the cilium in relation to osteoclasts, a hematopoietic cell responsible for bone resorption. The objective of this study was to determine whether osteoclasts have a primary cilium and to investigate whether or not the primary cilium of macrophages, osteoclast precursors, serves a functional role in osteoclast formation. Using immunocytochemistry, we showed the macrophages have a primary cilium, while osteoclasts lack this organelle. Furthermore, we increased macrophage primary cilia incidence and length using fenoldopam mesylate and found that cells undergoing such treatment showed a significant decrease in the expression of osteoclast markers tartrate-resistant acid phosphatase, cathepsin K, and c-Fos, as well as decreased osteoclast formation. This work is the first to show that macrophage primary cilia resorption may be a necessary step for osteoclast differentiation. Since primary cilia and preosteoclasts are responsive to fluid flow, we applied fluid flow at magnitudes present in the bone marrow to differentiating cells and found that osteoclastic gene expression by macrophages was not affected by fluid flow mechanical stimulation, suggesting that the role of the primary cilium in osteoclastogenesis is not a mechanosensory one. The primary cilium has been suggested to play a role in bone formation, and our findings indicate that it may also present a means to regulate bone resorption, presenting a dual benefit of developing ciliary-targeted pharmaceuticals for bone disease.
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Affiliation(s)
- Michael M. Sutton
- Department of Biomedical Engineering, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, NY, USA
| | - Michael P. Duffy
- Department of Biomedical Engineering, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, NY, USA
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stefaan W. Verbruggen
- Department of Biomedical Engineering, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, NY, USA
- Centre for Predictive in vitro Models, School of Engineering and Materials Science, Queen Mary University of London, London, UK
- Department of Mechanical Engineering and INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - Christopher R. Jacobs
- Department of Biomedical Engineering, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, NY, USA
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Ayers C, Kansagara D, Lazur B, Fu R, Kwon A, Harrod C. Effectiveness and Safety of Treatments to Prevent Fractures in People With Low Bone Mass or Primary Osteoporosis: A Living Systematic Review and Network Meta-analysis for the American College of Physicians. Ann Intern Med 2023; 176:182-195. [PMID: 36592455 DOI: 10.7326/m22-0684] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The prevalence of osteoporosis is increasing in the United States. PURPOSE To evaluate low bone mass and osteoporosis treatments to prevent fractures. DATA SOURCES Ovid MEDLINE ALL, Ovid Evidence Based Medicine Reviews: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov from 2014 through February 2022. STUDY SELECTION Adults receiving eligible interventions for low bone mass or osteoporosis. Randomized controlled trials (RCTs) for fracture outcomes, and RCTs and large observational studies (n ≥1000) for harms. DATA EXTRACTION Abstracted by 1 reviewer and verified by a second. Independent, dual assessments of risk of bias and certainty of evidence (CoE). DATA SYNTHESIS We included 34 RCTs (in 100 publications) and 36 observational studies. Bisphosphonates and denosumab reduced hip, clinical and radiographic vertebral, and other clinical fractures in postmenopausal females with osteoporosis (moderate to high CoE). Bisphosphonates for 36 months or more may increase the risk for atypical femoral fractures (AFFs) and osteonecrosis of the jaw (ONJ), but the absolute risks were low. Abaloparatide and teriparatide reduced clinical and radiographic vertebral fractures but increased the risk for withdrawals due to adverse events (WAEs; moderate to high CoE). Raloxifene and bazedoxifene for 36 months or more reduced radiographic vertebral but not clinical fractures (low to moderate CoE). Abaloparatide, teriparatide, and sequential romosozumab, then alendronate, may be more effective than bisphosphonates in reducing clinical fractures for 17 to 24 months in older postmenopausal females at very high fracture risk (low to moderate CoE). Bisphosphonates may reduce clinical fractures in older females with low bone mass (low CoE) and radiographic vertebral fractures in males with osteoporosis (low to moderate CoE). LIMITATION Few studies examined participants with low bone mass, males, or Black-identifying persons, sequential therapy, or treatment beyond 3 years. CONCLUSION Bisphosphonates, denosumab, abaloparatide, teriparatide, and romosozumab, followed by alendronate, reduce clinical fractures in postmenopausal females with osteoporosis. Abaloparatide and teriparatide increased WAEs; longer duration bisphosphonate use may increase AFF and ONJ risk though these events were rare. PRIMARY FUNDING SOURCE American College of Physicians. (PROSPERO: CRD42021236220).
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Affiliation(s)
- Chelsea Ayers
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon (C.A.)
| | - Devan Kansagara
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, and Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon (D.K.)
| | - Brittany Lazur
- Center for Evidence-based Policy, Oregon Health & Science University, Portland, Oregon (B.L.)
| | - Rongwei Fu
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon (R.F.)
| | - Amy Kwon
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon (A.K.)
| | - Curtis Harrod
- Division of General Internal Medicine & Geriatrics, Department of Medicine, and Center for Evidence-based Policy, Oregon Health & Science University, Portland, Oregon (C.H.)
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10
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Lippuner K, Moghadam BY, Schwab P. The osteoporosis treatment gap in Switzerland between 1998 and 2018. Arch Osteoporos 2023; 18:20. [PMID: 36650393 PMCID: PMC9845158 DOI: 10.1007/s11657-022-01206-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/19/2022] [Indexed: 01/19/2023]
Abstract
The annual number of patients treated for osteoporosis between 1998 and 2018 in Switzerland increased until 2008 and steadily decreased thereafter. With a continuously growing population at fracture risk exceeding an intervention threshold, the treatment gap has increased and the incidence of hip fractures has stopped declining in the past decade. INTRODUCTION The existence of an osteoporosis treatment gap, defined as the percentage of patients at risk for osteoporotic fractures exceeding an intervention threshold but remaining untreated, is widely acknowledged. Between 1998 and 2018, new bone active substances (BAS) indicated for the treatment of osteoporosis became available. Whether and if so to what extent these new introductions have altered the treatment gap is unknown. METHODS The annual number of patients treated with a BAS was calculated starting from single-drug unit sales. The number of patients theoretically eligible for treatment with a BAS was estimated based on four scenarios corresponding to different intervention thresholds (one based solely on a bone mineral density T score threshold and three FRAX-based thresholds) and the resulting annual treatment gaps were calculated. RESULTS In Switzerland, the estimated number of patients on treatment with a BAS increased from 35,901 in year 1998 to 233,381 in year 2018. However, this number grew regularly since 1998, peaked in 2008, and steadily decreased thereafter, in timely coincidence with the launch of intravenous bisphosphonates and the RANKL inhibitor denosumab. When expressed in numbers of untreated persons at risk for osteoporotic fractures exceeding a given intervention threshold, the treatment gaps were of similar magnitude in 1998 (when the first BSAs just had become available) and 2018. There was a strong association, which does not imply causation, between the proportion of patients treated and hip fracture incidence. CONCLUSION In Switzerland, the osteoporosis treatment gap has increased over the past decade. The availability of new BAS has not contributed to its decrease.
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Affiliation(s)
- Kurt Lippuner
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Bita Yousefi Moghadam
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Schwab
- Swiss Federal Statistical Office, Neuchâtel, Switzerland
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11
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Guthrie A, Fairman K, Gerber DK. Fractured Timelines: Reporting Patterns for Bisphosphonate-Associated Atypical Fractures and Implications for Postmarket Surveillance. Sr Care Pharm 2022; 37:555-564. [DOI: 10.4140/tcp.n.2022.555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Case reports of atypical fractures associated with bisphosphonates first appeared in the literature in 2005, with a larger number of reports published in 2007-2009. Objective To describe reporting trends of bisphosphonate-associated atypical
fractures relative to increasing awareness across medical and lay communities. Methods Disproportionality analyses were performed to assess odds of reporting atypical fractures associated with oral bisphosphonates using the US Food and Drug Administration (FDA) Adverse
Event Reporting System (FAERS) database. Reporting odds ratios (RORs) were assessed according to prespecified time periods (pre-awareness [1995-2006], growing-awareness [2007-2009], and post-warning [2010-2021]). Results There were 182 atypical fracture reports (n = 18
bisphosphonate-associated) during the pre-awareness period, 177 (n = 69 bisphosphonate-associated) during growing-awareness, and 6,170 (n = 3,150 bisphosphonate-associated) post-warning. Among reports by health care professionals, RORs for bisphosphonate-associated atypical fractures were
1.76, 13.49, and 12.16 across the three time periods. In comparison, RORs among all reporters (including consumers) increased from 1.50 to 7.95 to 18.93 across those three time periods. The highest proportion of reports during the pre-awareness period was for patients 51 to 65 years of age;
however, patients 66 years of age and older comprised the largest proportion of reports in the growing-awareness and post-warning periods. Discussion Reporting patterns for atypical fractures associated with bisphosphonate therapy appear to correlate with increasing awareness
among the medical and lay community. Conclusion As medication experts, pharmacists play a key role in recognizing risk factors for atypical fractures, utilizing the FDA’s system to support accurate event reporting, and promoting bisphosphonate deprescribing when clinically
appropriate.
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Affiliation(s)
- Ariane Guthrie
- Midwestern University College of Pharmacy—Glendale, Glendale, Arizona
| | - Kathleen Fairman
- Midwestern University College of Pharmacy—Glendale, Glendale, Arizona
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12
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Murphy B, Francis SL, Rhee I, Babazadeh S, Stoney J, Stevens J. Atypical femur fractures associated with bisphosphonate therapy: post-operative outcomes. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03314-y. [PMID: 35904634 DOI: 10.1007/s00590-022-03314-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/06/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Bisphosphonates are commonly used medication for the treatment of osteoporosis, and a well-established complication of this medication is bisphosphonate-associated atypical femur fractures (BAAFFs). The aim of this study was to assess the post-operative functional and radiographic outcomes of surgically treated BAAFFs. METHODS An analysis of patients treated at a university-affiliated institution was performed. Patients who had undergone surgical fixation for a subtrochanteric or shaft of femur fracture which had been classified as atypical and treated with bisphosphonate therapy at the time of fracture were included. The outcome measures assessed included post-operative complications, length of stay, discharge destination, post-operative function, independence in activities of daily living (ADLs) and fracture union. RESULTS Twenty patients were included in this study with a mean age of 75.2 years. The cohort was predominantly female. The average duration of bisphosphonate therapy was 7.35 years. Nine patients had contralateral bisphosphonate-related stress reactions at the time of their initial fracture and underwent prophylactic surgical intervention. The majority of patients received cephalomedullary nail fixation (95%) with more than half (65.0%) of the cohort experiencing one or more post-operative complications. The median length of stay was 6.5 days and 50% of the cohort required inpatient rehabilitation. At final review, independent mobilisation was recorded in only 10.0% of patients, and 70% of patients were dependent with their ADLs at their latest follow-up. Average follow-up was 8 months, and only six cases demonstrated union at the six-month review, with delayed union between 9 and 12 months being common. CONCLUSION Patients with BAAFFs experience high rates of complications, record poor post-operative functional outcomes, and demonstrate a delayed time to union. Nearly half of our cohort had radiographic evidence of bilateral pathology.
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Affiliation(s)
- Benjamin Murphy
- Department of Orthopaedics, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Sam L Francis
- Department of Orthopaedics, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia
| | - Isaac Rhee
- Department of Orthopaedics, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Sina Babazadeh
- Department of Orthopaedics, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia
| | - James Stoney
- Department of Orthopaedics, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Jarrad Stevens
- Department of Orthopaedics, St Vincent's Hospital, Melbourne, VIC, Australia.
- Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia.
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13
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Bisphosphonate Drug Holiday and Fracture Risk: Reviewing the Evidence. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2022. [DOI: 10.1007/s40674-022-00191-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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14
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Spasic M, Duffy MP, Jacobs CR. Fenoldopam Sensitizes Primary Cilia-Mediated Mechanosensing to Promote Osteogenic Intercellular Signaling and Whole Bone Adaptation. J Bone Miner Res 2022; 37:972-982. [PMID: 35230705 PMCID: PMC9098671 DOI: 10.1002/jbmr.4536] [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: 06/28/2021] [Revised: 02/01/2022] [Accepted: 02/12/2022] [Indexed: 11/05/2022]
Abstract
Bone cells actively respond to mechanical stimuli to direct bone formation, yet there is no current treatment strategy for conditions of low bone mass and osteoporosis designed to target the inherent mechanosensitivity of bone. Our group has previously identified the primary cilium as a critical mechanosensor within bone, and that pharmacologically targeting the primary cilium with fenoldopam can enhance osteocyte mechanosensitivity. Here, we demonstrate that potentiating osteocyte mechanosensing with fenoldopam in vitro promotes pro-osteogenic paracrine signaling to osteoblasts. Conversely, impairing primary cilia formation and the function of key ciliary mechanotransduction proteins attenuates this intercellular signaling cascade. We then utilize an in vivo model of load-induced bone formation to demonstrate that fenoldopam treatment sensitizes bones of both healthy and osteoporotic mice to mechanical stimulation. Furthermore, we show minimal adverse effects of this treatment and demonstrate that prolonged treatment biases trabecular bone adaptation. This work is the first to examine the efficacy of targeting primary cilia-mediated mechanosensing to enhance bone formation in osteoporotic animals. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Milos Spasic
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Michael P Duffy
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
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15
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Walker LE, Cooper C. Long-term bisphosphonate therapy and atypical femoral fracture: Can you have too much of a good thing? Br J Clin Pharmacol 2021; 87:4877-4879. [PMID: 34679224 DOI: 10.1111/bcp.15110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/16/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
Abstract
The long-term, continuous use of bisphosphonates (beyond 5 years) is not wholly without risk. Atypical femoral fracture is an uncommon but potentially very serious adverse event associated with the long-term use of bisphosphonates. Here we consider the complexities of long-term bisphosphonate prescribing, particularly in those that are low risk of osteoporotic fracture, wherein the duration of therapy should be reviewed regularly with individualised risk assessment to ensure the duration of treatment is appropriate.
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Affiliation(s)
- Lauren E Walker
- The Wolfson Centre for Personalised Medicine, School of Life Sciences, Biosciences Building, Crown Street, University of Liverpool, Liverpool, L69 7BE, United Kingdom
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton
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16
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Papapoulos S, Bone H, Cosman F, Dempster DW, McClung MR, Nakamura T, Restrepo JFM, Bouxsein ML, Cohn D, de Papp A, Massaad R, Santora A. Incidence of Hip and Subtrochanteric/Femoral Shaft Fractures in Postmenopausal Women With Osteoporosis in the Phase 3 Long-Term Odanacatib Fracture Trial. J Bone Miner Res 2021; 36:1225-1234. [PMID: 33724542 DOI: 10.1002/jbmr.4284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/01/2021] [Accepted: 03/08/2021] [Indexed: 12/23/2022]
Abstract
We prospectively assessed, with predefined criteria, the location and rates of all femur fractures (hip, subtrochanteric/femoral shaft [ST/FS], including atypical [AFF] and distal fractures) in women at increased fracture risk during treatment with the cathepsin K inhibitor, odanacatib (ODN), or placebo over 5 years in the Long-Term ODN Fracture Trial (LOFT and LOFT Extension [NCT00529373, EudraCT 2007-002693-66]). ODN was an investigational antiresorptive agent previously in development as an osteoporosis treatment that, unlike bisphosphonates, reduces bone formation only transiently. Women aged ≥65 years with a bone mineral density (BMD) T-score ≤-2.5 at the total hip (TH) or femoral neck (FN) or with a radiographic vertebral fracture and T-scores ≤-1.5 at the TH or FN were randomized (1:1) to receive ODN 50 mg/week or placebo. All patients received vitamin D3 (5600 IU/week) and calcium (total 1200 mg/d); the analysis included 16,071 women. Rates of all adjudicated low-energy femoral fractures were 0.38 versus 0.58/100 patient-years for ODN and placebo, respectively (hazard ratio [HR] = 0.65; 95% confidence interval [CI] 0.51-0.82; nominal p < .001), and for low-energy hip fractures were 0.29 versus 0.56/100 patient-years, respectively (HR = 0.52; 95% CI 0.40-0.67; p < .001). The cumulative incidence of combined hip and ST/FS or hip fractures alone in the ODN group was consistently lower than in the placebo group (1.93% versus 3.11% for combined fractures and 1.53% versus 3.03% for hip fractures at 5 years, respectively). However, low-energy ST/FS fractures were more frequent in ODN-treated women than in placebo-treated women (24 versus 6, respectively). Among these, 12 fractures were adjudicated as AFF in 10 patients treated with ODN (0.03/100 patient-years) compared with none in the 6 placebo-treated women (estimated difference 0.03; 95% CI 0.02-0.06). These results provide insight into possible pathogeneses of AFF, suggesting that the current criteria for diagnosing these fractures may need to be reconsidered. © 2021 American Society for Bone and Mineral Research (ASBMR)..
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Affiliation(s)
| | - Henry Bone
- Michigan Bone & Mineral Clinic, Detroit, MI, USA
| | | | | | - Michael R McClung
- Oregon Osteoporosis Center, Portland, OR, USA.,Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | | | | | - Mary L Bouxsein
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, and Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA
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17
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Tresguerres FGF, Tresguerres IF, Leco I, Clemente C, Rodríguez-Torres R, Torres J, Carballido J, Tresguerres JAF. Growth Hormone As Antiaging Factor in Old Bones. Rejuvenation Res 2021; 24:354-365. [PMID: 33906424 DOI: 10.1089/rej.2020.2369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aging induces changes in bone. Growth hormone (GH) is reduced by aging, and age-related changes observed in old bones might be due to a decrease in the GH/insulin-like growth factor-I (IGF-I) axis. GH administration on aged individuals is controversial. This study aimed to assess the effect of systemic GH treatment on bone properties, bone metabolism, and bone mineral density (BMD) in long bone of old rats. Aged Wistar rats were treated with GH at a dose of 2 mg/kg/day during 10 weeks. Plasma osteocalcin, IGF-I, and carboxy-terminal telopeptide of type I collagen levels were measured. Cross-sectional bone areas and BMD were measured by morphometric and densitometric analysis, respectively. Femora were analyzed by three point-bending testing. t-Test was used for statistical evaluation. p < 0.05 was considered to be significant. Significantly enhanced bone area, at the expense of the cortical area, was found in treated rats. The densitometric analysis showed 11% higher BMD in the experimental group. Significantly higher bone flexural modulus, stiffness, and ultimate load were observed in the treated rats. Plasma osteocalcin and IGF-I levels were significantly increased in the treated group, while the resorption marker concentration remained unchanged. Within the limitations of this experimental study, systemic GH administration has shown to enhance biomechanical properties, BMD, cortical mass, and plasma IGF-I and osteocalcin in old treated rats, compared to the control group; consequently, GH could be considered as an alternative therapy against age-related changes in the bone.
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Affiliation(s)
- Francisco G F Tresguerres
- Department of Dental Clinical Specialities, Faculty of Dentistry, Complutense University, Madrid, Spain
| | - Isabel F Tresguerres
- Department of Dental Clinical Specialities, Faculty of Dentistry, Complutense University, Madrid, Spain
| | - Isabel Leco
- Department of Dental Clinical Specialities, Faculty of Dentistry, Complutense University, Madrid, Spain
| | - Celia Clemente
- Department of Human Anatomy and Embryology, Faculty of Medicine, University of Alcala, Madrid, Spain
| | - Rosa Rodríguez-Torres
- Department of Human Anatomy and Embryology, Faculty of Medicine, University of Alcala, Madrid, Spain
| | - Jesús Torres
- Department of Dental Clinical Specialities, Faculty of Dentistry, Complutense University, Madrid, Spain
| | - Jorge Carballido
- Department of Dental Clinical Specialities, Faculty of Dentistry, Complutense University, Madrid, Spain
| | - Jesús A F Tresguerres
- Department of Physiology, Faculty of Medicine, Complutense University, Madrid, Spain
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18
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Giannoudis V, Guy S, Romano R, Carsten O, Pandit H, van Duren B. Doctor when can I drive? Braking response after knee arthroplasty: A systematic review & meta-analysis of brake reaction time. Knee 2021; 30:214-240. [PMID: 33945981 DOI: 10.1016/j.knee.2021.03.013] [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: 09/01/2020] [Revised: 12/18/2020] [Accepted: 03/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is limited evidence available on return to driving for patients undergoing knee arthroplasty (KA). Primarily, surgeons have used brake reaction time as a surrogate measure of safe return to driving. The purpose of this study was to review existing literature and provide guidance on the recovery of braking performance following knee arthroplasty. METHODS A literature search was performed for prospective studies on driving after KA. Two reviewers screened citations for inclusion, assessed methodological quality, and extracted data. Values for total brake reaction-time (TBRT), movement-time (MT), reaction-time (RT), and braking-force (BF) were included for meta-analysis. RESULTS Twelve studies with 368 subjects were identified. TBRT, RT, MT, and BF relative to preoperative baseline were assessed. Meta-analysis of TBRT showed a significant improvement from preoperative baseline at 3 months & 1 year (p = 0.003 & p = 0.0001). MT showed a significant increase at 2 and 4 weeks (p = 0.00001 & p = 0.03) before returning to no being significantly different at 6 weeks and beyond. In contrast RTs were noted to improve significantly 2 weeks (p = 0.006), 4 weeks (p = 0.03), and 1 year (p = 0.0002). CONCLUSION Meta-analysis showed no significant difference in TBRT up until 3 months. RT increased significantly post-operatively suggesting it is not a reliable indicator. MT in contrast was significantly decreased post KA and may represent a more reliable measure of braking performance post KA. Surgeons should consider these recommendations and other patient factors that determine fitness to drive prior to advising their patients on a safe to return to driving.
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Affiliation(s)
- Vasileios Giannoudis
- Leeds Orthopaedic & Trauma Sciences, School of Medicine, University of Leeds, United Kingdom
| | | | - Richard Romano
- Institute for Transport Studies, University of Leeds, United Kingdom
| | - Oliver Carsten
- Institute for Transport Studies, University of Leeds, United Kingdom
| | - Hemant Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, United Kingdom
| | - Bernard van Duren
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, United Kingdom.
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19
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Lo JC, Neugebauer RS, Ettinger B, Chandra M, Hui RL, Ott SM, Grimsrud CD, Izano MA. Risk of complete atypical femur fracture with Oral bisphosphonate exposure beyond three years. BMC Musculoskelet Disord 2020; 21:801. [PMID: 33272248 PMCID: PMC7713036 DOI: 10.1186/s12891-020-03672-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 09/24/2020] [Indexed: 11/10/2022] Open
Abstract
Background Bisphosphonate (BP) therapy has been associated with atypical femur fracture (AFF). However, the threshold of treatment duration leading to increased AFF risk is unclear. In a retrospective cohort of older women initiating BP, we compared the AFF risk associated with treatment for at least three years to the risk associated with treatment less than three years. Methods We used observational data from a large population of female members of an integrated healthcare system who initiated oral BP during 2002–2014. Women were retrospectively followed for incident AFF confirmed by radiologic adjudication. Demographic data, pharmacologic exposures, comorbidity, bone density, and fracture history were ascertained from electronic health records. Inverse probability weighting was used to estimate risk differences comparing the cumulative incidence (risk) of AFF if women discontinued BP within three years to the cumulative incidence of AFF if women continued BP for three or more years, adjusting for potential time-dependent confounding by the aforementioned factors. Results Among 87,820 women age 45–84 years who initiated BP (mean age 68.6, median T-score − 2.6, 14% with prior major osteoporotic fracture), 16,180 continued BP for three or more years. Forty-six confirmed AFFs occurred during follow-up in the two groups. AFF-free survival was greater for BP treatment < 3 years compared to treatment ≥3 years (p = 0.004 comparing areas under survival curves). At five years, the risk of AFF was 27 per 100,000 (95% confidence interval, CI: 8–46) if women received BP treatment < 3 years and 120 per 100,000 (95% CI: 56–183) if women received BP treatment ≥3 years (risk difference 93 per 100,000, 95% CI: 30–160). By ten years, the risks were 27 (95% CI: 8–46) and 363 (95% CI: 132–593) per 100,000 for BP treatment < 3 and ≥ 3 years, respectively (risk difference 336 per 100,000, 95% CI: 110–570). Conclusions Bisphosphonate treatment for 3 or more years was associated with greater risk of AFF than treatment for less than 3 years. Although AFFs are uncommon among BP-treated women, this increased risk should be considered when counseling women about long-term BP use. Future studies should further characterize the dose-response relationship between BP duration and incident AFF and identify patients at highest risk.
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Affiliation(s)
- Joan C Lo
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA. .,The Permanente Medical Group, Oakland, CA, USA.
| | - Romain S Neugebauer
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.,The Permanente Medical Group, Oakland, CA, USA
| | - Bruce Ettinger
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Malini Chandra
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Rita L Hui
- Pharmacy Outcomes Research Group, Kaiser Permanente California, Oakland, CA, USA
| | - Susan M Ott
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Christopher D Grimsrud
- The Permanente Medical Group, Oakland, CA, USA.,Department of Orthopedic Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Monika A Izano
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
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20
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Abe K, Kimura H, Yamamoto N, Shimozaki S, Higuchi T, Taniguchi Y, Uto T, Tsuchiya H. Treatment strategy for atypical ulnar fracture due to severely suppressed bone turnover caused by long-term bisphosphonate therapy: a case report and literature review. BMC Musculoskelet Disord 2020; 21:802. [PMID: 33272231 PMCID: PMC7712635 DOI: 10.1186/s12891-020-03824-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Atypical fractures may occur due to the combined effect of severely suppressed bone turnover (SSBT) caused by long-term bisphosphonate treatment and chronic repetitive bone microdamage. Atypical fracture of the ulna due to SSBT is a rare entity; there is no standardized treatment strategy for this condition. We successfully treated a patient with atypical fracture of the ulna. Herein, we present this patient, review the relevant literature, and discuss the treatment strategy. CASE PRESENTATION An 84-year-old woman presented with atypical fracture of the left ulnar shaft due to SSBT. She had a history of bisphosphonate therapy (ibandronate and alendronate) since more than 10 years; her bone turnover was severely suppressed. We performed open reduction and internal fixation (ORIF) using dual plate with some additional treatments. These included drilling and decortication, use of autogenous bone graft, low-intensity pulsed ultrasound (LIPUS) treatment, and administration of teriparatide. Finally, bone union was observed at 11 months after surgery. CONCLUSIONS Based on the literature review and our experience with this case, ORIF alone may not be adequate to achieve bone union; drilling, decortication, and use of cancellus bone graft is important to achieve favorable outcomes. Administration of teriparatide and LIPUS may facilitate early bone union, although further studies are required to provide more definitive evidence. Furthermore, ORIF using dual plate may help avoid implant failure owing to the long time required for bone union.
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Affiliation(s)
- Kensaku Abe
- Department of Orthopaedic Surgery, Japanese Red Cross Kanazawa Hospital, 2-251 Minma, Kanazawa, 921-8162, Japan
| | - Hiroaki Kimura
- Department of Orthopaedic Surgery, Japanese Red Cross Kanazawa Hospital, 2-251 Minma, Kanazawa, 921-8162, Japan.
| | - Norio Yamamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Shingo Shimozaki
- Department of Orthopaedic Surgery, Japanese Red Cross Kanazawa Hospital, 2-251 Minma, Kanazawa, 921-8162, Japan
| | - Takashi Higuchi
- Department of Orthopaedic Surgery, Japanese Red Cross Kanazawa Hospital, 2-251 Minma, Kanazawa, 921-8162, Japan
| | - Yuta Taniguchi
- Department of Orthopaedic Surgery, Japanese Red Cross Kanazawa Hospital, 2-251 Minma, Kanazawa, 921-8162, Japan
| | - Takaaki Uto
- Department of Orthopaedic Surgery, Japanese Red Cross Kanazawa Hospital, 2-251 Minma, Kanazawa, 921-8162, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
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21
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Ueda M, Kami M. Atypical Femur Fracture Risk versus Fragility Fracture Prevention with Bisphosphonates. N Engl J Med 2020; 383:2188-2189. [PMID: 33252880 DOI: 10.1056/nejmc2029828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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22
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Heckmann ND, Yang J, DeBenedetti A, Della Valle CJ. Atypical Subtrochanteric Femur Fracture and Hip Osteoarthritis Treated with a Revision Monoblock Stem and Strut Allograft: A Case Report. JBJS Case Connect 2020; 10:e2000038. [PMID: 32960023 DOI: 10.2106/jbjs.cc.20.00038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 73-year-old woman was diagnosed with a nondisplaced incomplete atypical bisphosphonate-related subtrochanteric femur fracture and ipsilateral hip osteoarthritis. She was treated with a total hip arthroplasty using a monoblock revision stem and a strut allograft to provide adjunctive mechanical and biological support. At the final follow-up, the patient had no pain, the stem was well fixed, and the allograft strut had incorporated; however, a persistent fracture line was noted. CONCLUSION When an atypical femur fracture coexists with hip osteoarthritis, total hip arthroplasty may be a reasonable treatment option to address the fracture and concomitant hip osteoarthritis with a single surgical intervention. However, consideration should be given to using a stem with distal fixation and augmenting the construct with a strut allograft.
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Affiliation(s)
- Nathanael D Heckmann
- 1Department of Orthopaedic Surgery, Keck Medicine of USC, Los Angeles, California 2Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Chiu E, Cabanero M, Sidhu G. Paradoxical Stress Fracture in a Patient With Multiple Myeloma and Bisphosphonate Use. Cureus 2020; 12:e9837. [PMID: 32953344 PMCID: PMC7496493 DOI: 10.7759/cureus.9837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Multiple myeloma (MM) is a plasma cell disorder with related organ dysfunction, including hypercalcemia, renal insufficiency, anemia, and bone disease. Osteolytic bone lesions that result in pain and pathologic fractures are a major source of morbidity and the use of bisphosphonates is generally safe and effective treatment in reducing myeloma-related skeletal fractures and associated morbidity. We present a 73-year-old African American woman with MM in remission and on intravenous (IV) bisphosphonate therapy in the past five years who reported gradually worsening bilateral thigh pain of six months duration. A bone survey showed no neoplastic focus, and bilateral hip X-rays showed incomplete insufficiency stress fractures with characteristic features suspicious for bisphosphonate-related atypical femoral fracture (AFF). Increasingly reported in the literature, bilateral AFF is a unique and serious adverse effect for patients on bisphosphonates. Our case illustrates the distinct challenges in managing a patient with MM on long-term bisphosphonate therapy who suffered bilateral atypical femoral fractures, an uncommon presentation of a relatively rare phenomenon. It is important to balance the established benefits of bisphosphonate therapy with potential fracture risk and be particularly vigilant about adverse effect monitoring and timely intervention.
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Affiliation(s)
- Edwin Chiu
- Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, USA
| | | | - Gurinder Sidhu
- Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, USA
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Canbek U, Akgun U, Soylemez D, Canbek TD, Aydogan NH. Incomplete atypical femoral fractures after bisphosphonate use in postmenopausal women. J Orthop Surg (Hong Kong) 2020; 27:2309499019875262. [PMID: 31547771 DOI: 10.1177/2309499019875262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE This study aimed to determine the prevalence of incomplete atypical femoral fractures (iAFFs) in postmenopausal women using bisphosphonates and to investigate the potential risk factors for the development of iAFF. METHODS The national health-care records system indicated that 2746 postmenopausal women in our region aged ≥50 years were taking bisphosphonates. Using an assumed iAFF prevalence of 10% and levels of 5% α significance and ±5% precision, we calculated that a sample size of 132 participants was needed for this study. The patients were randomly selected and invited to the hospital. Radiographs and bone scans were used to evaluate each patient for iAFF. Bone mineral density, 25-hydroxy vitamin D, parathyroid hormone, and alkaline phosphatase measurements were performed. RESULTS The mean age of the study population was 72.79 ± 7.35 years, and the mean duration of bisphosphonate use was 7.7 ± 3.4 years. We found iAFF in 14 (10.6%) patients, and 3 patients had bilateral involvement. Of the 17 femurs with iAFF, a proximal third location was seen in 2 patients (11.8%), a mid-third location in 14 (82.4%), and a distal third location in 1 (5.9%). The duration of bisphosphonate use was longer, and parathyroid hormone levels were higher in patients with iAFF compared to those without an incomplete fracture. CONCLUSION We found a relatively higher prevalence of iAFF in postmenopausal women using bisphosphonate. Early identification and treatment of iAFF is crucial for reducing potential patient morbidity and hospital costs.
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Affiliation(s)
- Umut Canbek
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Ulas Akgun
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Deniz Soylemez
- Department of Nuclear Medicine, Mugla Sitki Kocman University Training and Research Hospital, Mugla, Turkey
| | - Tugba Dubektas Canbek
- Department of Internal Medicine, Mugla Sitki Kocman University Training and Research Hospital, Mugla, Turkey
| | - Nevres Hurriyet Aydogan
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
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Comparative safety and effectiveness of alendronate versus raloxifene in women with osteoporosis. Sci Rep 2020; 10:11115. [PMID: 32632237 PMCID: PMC7338498 DOI: 10.1038/s41598-020-68037-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 06/16/2020] [Indexed: 12/14/2022] Open
Abstract
Alendronate and raloxifene are among the most popular anti-osteoporosis medications. However, there is a lack of head-to-head comparative effectiveness studies comparing the two treatments. We conducted a retrospective large-scale multicenter study encompassing over 300 million patients across nine databases encoded in the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). The primary outcome was the incidence of osteoporotic hip fracture, while secondary outcomes were vertebral fracture, atypical femoral fracture (AFF), osteonecrosis of the jaw (ONJ), and esophageal cancer. We used propensity score trimming and stratification based on an expansive propensity score model with all pre-treatment patient characteritistcs. We accounted for unmeasured confounding using negative control outcomes to estimate and adjust for residual systematic bias in each data source. We identified 283,586 alendronate patients and 40,463 raloxifene patients. There were 7.48 hip fracture, 8.18 vertebral fracture, 1.14 AFF, 0.21 esophageal cancer and 0.09 ONJ events per 1,000 person-years in the alendronate cohort and 6.62, 7.36, 0.69, 0.22 and 0.06 events per 1,000 person-years, respectively, in the raloxifene cohort. Alendronate and raloxifene have a similar hip fracture risk (hazard ratio [HR] 1.03, 95% confidence interval [CI] 0.94–1.13), but alendronate users are more likely to have vertebral fractures (HR 1.07, 95% CI 1.01–1.14). Alendronate has higher risk for AFF (HR 1.51, 95% CI 1.23–1.84) but similar risk for esophageal cancer (HR 0.95, 95% CI 0.53–1.70), and ONJ (HR 1.62, 95% CI 0.78–3.34). We demonstrated substantial control of measured confounding by propensity score adjustment, and minimal residual systematic bias through negative control experiments, lending credibility to our effect estimates. Raloxifene is as effective as alendronate and may remain an option in the prevention of osteoporotic fracture.
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Roh YH, Kim KH, Yoon KS, Ha YC, Yoo SJ, Nam KW. Unique Form of Atypical Subtrochanteric Femoral Fracture at the Medial Cortex: A Report of 3 Cases. JBJS Case Connect 2020; 10:e1900545. [PMID: 32865952 DOI: 10.2106/jbjs.cc.19.00545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE Three women with unique subtrochanteric femoral fracture occurring at the medial cortex of the femur are presented. One patient had been on drug holiday for the past 2 years after 3 years of risedronate use; the other patients had been taking alendronate for osteoporosis for 4 years and 20 years without drug holiday. CONCLUSION The fractures met all major criteria for the revised case definition of atypical femoral fracture (AFF) provided by the American Society of Bone and Mineral Research task force except for the location. Hence, we report 3 cases of AFFs developing in the subtrochanteric medial femoral cortex.
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Affiliation(s)
- Young Ho Roh
- 1Department of Orthopedic Surgery, School of Medicine Jeju National University, Jeju, Korea 2Department of Orthopedic Surgery, Kangwon National University Hospital, Chuncheon, Korea 3Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea 4Department of Orthopedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea
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Fülling T, Bula P, Defèr A, Bonnaire FA. Dresdener Network Osteoporosis. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2020; 159:438-446. [PMID: 32428959 DOI: 10.1055/a-1149-9588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE On a global scale the main focus of traumatological therapy lies in the treatment of unintentional injuries or victims of violence. People of all ages and through all economic groups can be affected. Due to demographic change in Western industrial countries, however, this focus increasingly shifts towards fragility fractures. In Europe osteoporosis is the most common bone disease in advanced age. Secondary prevention programs like the Fracture Liaison Service (FLS) are becoming increasingly prevalent, especially in Anglo-American health care systems. In German orthopedic and trauma wards and hospitals, however, the FLS is still relatively uncommon. This article will examine the question whether secondary prevention programs like FLS need to be established in the German health care system. This study aims at finding out, whether in the area of a medium sized German city there is a difference regarding the initiation of osteoporosis diagnosis and therapy between the regular aftercare by the general practitioner or the orthopedic surgeon and the aftercare by a specialist trained in osteology (Osteologe). MATERIALS AND METHODS For the open, randomized prospective study 70 patients with low energy fractures were recruited, who were older than 60 years and have been treated in our department. RESULTS 58 out of 70 patients have completed the study, which amounts to a follow-up of 82.9%. Limited mobility and a high degree of organizational effort were the main reasons for early termination of the study. While in the group with regular aftercare, only 2 out of 29 patients received a specific osteoporosis treatment, in group who were directly transferred to a specialist trained in osteology 17 out of 29 patients received specific treatment. After re-evaluation of group with regular aftercare in 21 out of 29 cases a specific osteoporosis treatment was recommended. CONCLUSIONS It could be established that there is a significant diagnosis and treatment gap regarding the aftercare of patients with fractures caused by osteoporosis between general practitioners or orthopedic surgeons on the one hand and the specialists trained in osteology on the other hand. To improve the aftercare of fracture patients, cross sectoral networks with a background in geriatrics and orthopedic-trauma surgery like a FLS need to be established in the German healthcare system.
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Affiliation(s)
- Tim Fülling
- Department of Trauma, Reconstructive and Hand Surgery, Dresden Municipal Hospital
| | - Philipp Bula
- Department of Trauma and Reconstructive Surgery, Orthopaedic, Plastic, Aesthetic and Hand Surgery, Gutersloh Municipal Hospital
| | | | - Felix Alois Bonnaire
- Department of Trauma, Reconstructive and Hand Surgery, Dresden Municipal Hospital
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Advanced Adrenocortical Carcinoma (ACC): a Review with Focus on Second-Line Therapies. Discov Oncol 2020; 11:155-169. [PMID: 32303972 DOI: 10.1007/s12672-020-00385-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/01/2020] [Indexed: 02/07/2023] Open
Abstract
Advanced adrenocortical cancer (ACC) is a rare, highly aggressive malignancy, which typically has a poor prognosis. In advanced ACC, the overall trend is toward a short PFS interval following first-line systemic therapy, highlighting a clear need for improved second-/third-line treatment strategies. We conducted a review of the literature and relevant scientific guidelines related to systemic therapy for advanced ACC. Public indexes including PubMed/MEDLINE were searched. Treatment selection in the second-line setting is based on small phase 2 trials, case reports, and pre-clinical evidence. The best data available for initial second-line therapy selection supports the use of gemcitabine and capecitabine (G + C) or streptozotocin (S), both with or without mitotane. G + C is becoming increasingly recommended based on phase 2 clinical trial data in patients of good PS, due to the inferred superior PFS and OS from non-comparative trials. Alternatively, streptozotocin was better tolerated than EDP + M in the FIRM-ACT study and remains an option when warranted. Beyond this, further treatment approaches should be tailored to individual patient characteristics, utilizing a mixture of systemic therapies, local therapies, and enrolment in clinical trials where available. Additionally, the role of molecular stratification, predictive biomarkers, and immune checkpoint inhibitors in specific individuals, such as Lynch syndrome, is evolving and may become increasingly utilized in clinical practice. Advanced ACC necessitates a multidisciplinary approach and is best managed in a specialist center. Although there is no one definitive second-line treatment strategy, there are some favorable approaches, which require further validation in larger clinical trials.
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Rasmussen NH, Dal J, de Vries F, van den Bergh JP, Jensen MH, Vestergaard P. Diabetes and fractures: new evidence of atypical femoral fractures? Osteoporos Int 2020; 31:447-455. [PMID: 31838553 DOI: 10.1007/s00198-019-05224-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022]
Abstract
UNLABELLED Patients with diabetes have an increased risk of fractures. In this study, subtrochanteric and femoral shaft fractures were increased in patients with type 1 diabetes compared with the general population. In the light of this, more evidence points towards an association between diabetes and atypical femoral fractures. INTRODUCTION Patients with diabetes have an increased risk of femoral fractures, but little is known about the risk of atypical femoral fractures (AFFs). The aim of this study was to identify the risk of subtrochanteric and femoral shaft (ST/FS) fractures and estimate the risk of AFFs in patients with type 1 (T1D) and type 2 diabetes (T2D). METHODS From the nationwide Danish National Patient Register, we identified patients with T1D (n = 19,896), T2D (n = 312,188), and sex- and aged-matched controls without diabetes (n = 996,252) from the general population and all ST/FS fractures (n = 7509). Data were analyzed using a Cox proportional-hazards model and the incidence rate and rate ratio of ST/FS fractures were estimated. RESULTS The incidence rate of ST/FS fractures in T1D was 52.14 events per 100,000 person years and 73.21 per 100,000 person years in T2D. T1D was associated with an increased risk of ST/FS (HR 2.07 (95% CI 1.68-2.56)), whereas T2D was not (HR 0.99 (95% CI 0.94-1.10)). Previous ST/FS fractures were associated with an increased risk of subsequent ST/FS fractures (HR 6.95 (95% CI 6.00-8.05)) and the use of bisphosphonates with an increased risk of ST/FS fractures (HR 1.72 (95% CI 1.54-1.91)). CONCLUSION Patients with T1D have a higher risk of ST/FS fractures compared with sex- and age-matched controls. Since a proportion of ST/FS fractures are classified as AFFs, this could point towards the fact that AFFs also are increased in patients with T1D, but not T2D.
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Affiliation(s)
- N H Rasmussen
- Steno Diabetes Center North, Aalborg University Hospital, Aalborg, Denmark.
| | - J Dal
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - F de Vries
- Department of Clinical Pharmacy & Toxicology, Maastricht UMC+, Maastricht, The Netherlands
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - J P van den Bergh
- Department of Internal Medicine, VieCuri Medical Center, Venlo, The Netherlands
- Department of Internal Medicine, Maastricht UMC+, Maastricht, The Netherlands
- Faculty of Medicine and Life Sciences, University Hasselt, Hasselt, Belgium
| | - M H Jensen
- Steno Diabetes Center North, Aalborg University Hospital, Aalborg, Denmark
| | - P Vestergaard
- Steno Diabetes Center North, Aalborg University Hospital, Aalborg, Denmark
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30
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Tresguerres F, Torres J, López-Quiles J, Hernández G, Vega J, Tresguerres I. The osteocyte: A multifunctional cell within the bone. Ann Anat 2020; 227:151422. [DOI: 10.1016/j.aanat.2019.151422] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 01/09/2019] [Accepted: 09/16/2019] [Indexed: 12/31/2022]
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Iolascon G, Moretti A, Toro G, Gimigliano F, Liguori S, Paoletta M. Pharmacological Therapy of Osteoporosis: What's New? Clin Interv Aging 2020; 15:485-491. [PMID: 32273690 PMCID: PMC7105363 DOI: 10.2147/cia.s242038] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 02/07/2020] [Indexed: 02/05/2023] Open
Abstract
Osteoporosis and fragility fractures are relevant health issues because of their impact in terms of morbidity, mortality, and socioeconomic burden. Despite this alarming scenario, both underdiagnosis and undertreatment are common features of osteoporotic patients, particularly those who have already sustained a fragility fracture. Pharmacotherapy of osteoporosis is the main treatment option for these patients because of strong evidence about the efficacy of available drugs targeting bone metabolism. However, several issues can interfere with the effectiveness of anti-osteoporotic drugs in clinical practice, such as lack of awareness of both healthcare providers and patients, poor adherence to therapy, and safety in long-term treatment. Therefore, new therapeutic strategies have been proposed to overcome these problems, such as sequential therapy or emerging molecules mainly targeting the stimulation of bone formation. In particular, abaloparatide has been demonstrated to reduce major nonvertebral fracture risk compared with both placebo and teriparatide, although the European Medicines Agency (EMA) refused the marketing authorization because the benefits of this drug did not outweigh its risks. On the other side, EMA has recently approved romosozumab, a monoclonal antibody directed against sclerostin and the only available therapeutic option targeting Wnt signaling, as both bone-forming and antiresorptive intervention to treat osteoporosis and fragility fractures.
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Affiliation(s)
- Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
- Correspondence: Antimo Moretti Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy Email
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Francesca Gimigliano
- Department of Physical and Mental Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Sara Liguori
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
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Abstract
PURPOSE OF REVIEW This article summarizes the risk factors for atypical femur fractures (AFF), discusses current and emerging imaging modalities for early identification of AFF, and offers recommendations for prevention and management of AFFs based on the current concepts. RECENT FINDINGS Antiresorptive therapies are widely recommended for prevention and treatment of osteoporosis. Despite their well established effectiveness to reduce fracture risk, emerging concerns related to potential adverse effects have led to a substantial decline in the use of bisphosphonates. Although, the pathogenesis of AFF has not yet been elucidated, the bulk of evidence supports that the well known therapeutic benefits of bisphosphonate far outweigh the relatively low risk of AFFs. Recommendations for early identification of patients at risk for AFF using radiographic imaging have been established. Consensus on the management of AFF and osteoporosis in patients with AFF needs to be formulated. SUMMARY AFF is a rare event associated with long-term bisphosphonate therapy, which represents an apparent paradox in the management of osteoporosis. Improved understanding of pathogenetic mechanisms will be helpful in further refining of screening guidelines and standardization of management and treatment strategies.
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Affiliation(s)
- Vidita Divan
- Metabolic Bone Disease Center, State University of New York Upstate Medical University, Syracuse, New York
| | - Sudhaker D Rao
- Bone and Mineral Research Laboratory, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ruban Dhaliwal
- Metabolic Bone Disease Center, State University of New York Upstate Medical University, Syracuse, New York
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Dennison EM, Cooper C, Kanis JA, Bruyère O, Silverman S, McCloskey E, Abrahamsen B, Prieto-Alhambra D, Ferrari S. Fracture risk following intermission of osteoporosis therapy. Osteoporos Int 2019; 30:1733-1743. [PMID: 31175404 DOI: 10.1007/s00198-019-05002-w] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/26/2019] [Indexed: 11/27/2022]
Abstract
Given the widespread practice of recommending drug holidays, we reviewed the impact of medication discontinuation of two common anti-osteoporosis therapies (bisphosphonates and denosumab). Trial evidence suggests the risk of new clinical fractures, and vertebral fracture increases when osteoporosis treatment with bisphosphonates or denosumab is stopped. INTRODUCTION The aim of this paper was to review the available literature to assess what evidence exists to inform clinical decision-making with regard to drug holidays following treatment with bisphosphonates (BiP) or denosumab. METHODS Systematic review. RESULTS Differing pharmacokinetics lead to varying outcomes on stopping therapy. Prospective and retrospective analyses report that the risk of new clinical fractures was 20-40% higher in subjects who stopped BiP treatment, and vertebral fracture risk was approximately doubled. Rapid bone loss has been well described following denosumab discontinuation with an incidence of multiple vertebral fractures around 5%. Studies have not identified risk factors for fracture after stopping treatment other than those that provide an indication for treatment (e.g. prior fracture and low BMD). Studies that considered long-term continuation did not identify increased fracture risk, and reported only very low rates of adverse skeletal events such as atypical femoral fracture. CONCLUSIONS The view that patients on long-term treatment with bisphosphonates or denosumab should always be offered a drug holiday is not supported by the existing evidence. Different pharmacokinetic properties for different therapies require different strategies to manage drug intermission. In contrast, long-term treatment with anti-resorptives is not associated with increased risk of fragility fractures and skeletal adverse events remain rare.
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Affiliation(s)
- E M Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK.
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, University of Sheffield, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - O Bruyère
- World Health Organization Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - S Silverman
- Cedars-Sinai/UCLA Medical Center and OMC Clinical Research Center, Beverly Hills, CA, USA
| | - E McCloskey
- Academic Unit of Bone Metabolism, Department of Oncology and Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK
| | - B Abrahamsen
- Department of Medicine, Holbaek Hospital, Holbaek, Denmark
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - D Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- GREMPAL Research Group, Idiap Jordi Gol and CIBERFes, Universitat Autonoma de Barcelona and Instituto de Salud Carlos III, Barcelona, Spain
| | - S Ferrari
- Division of Bone Disease, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
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Reid IR, Horne AM, Mihov B, Stewart A, Garratt E, Wiessing KR, Bolland MJ, Bastin S, Gamble GD. Anti-fracture efficacy of zoledronate in subgroups of osteopenic postmenopausal women: secondary analysis of a randomized controlled trial. J Intern Med 2019; 286:221-229. [PMID: 30887607 DOI: 10.1111/joim.12901] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND We recently reported that the administration of zoledronate every 18 months to osteopenic older women reduces the incidence of fractures. OBJECTIVE Here, we present a more detailed analysis of that trial to determine whether baseline clinical characteristics impact on the anti-fracture efficacy of this intervention. METHODS This is a prospective, randomized, placebo-controlled, double-blind trial in osteopenic postmenopausal women aged ≥ 65 years, to determine the anti-fracture efficacy of zoledronate. 2000 women were recruited using electoral rolls and randomized to receive 4 infusions of either zoledronate 5 mg or normal saline, at 18-month intervals. Each participant was followed for 6 years. Calcium supplements were not supplied. RESULTS Fragility fractures (either vertebral or nonvertebral) occurred in 190 women in the placebo group (227 fractures) and in 122 women in the zoledronate group (131 fractures), odds ratio (OR) 0.59 (95%CI 0.46, 0.76; P < 0.0001). There were no significant interactions between baseline variables (age, anthropometry, BMI, dietary calcium intake, baseline fracture status, recent falls history, bone mineral density, calculated fracture risk) and the treatment effect. In particular, the reduction in fractures appeared to be independent of baseline fracture risk, and numbers needed to treat (NNT) to prevent one woman fracturing were not significantly different across baseline fracture risk tertiles. CONCLUSIONS The present analyses indicate that the decrease in fracture numbers is broadly consistent across this cohort. The lack of relationship between NNTs and baseline fracture risk calls into question the need for BMD measurement and precise fracture risk assessment before initiating treatment in older postmenopausal women.
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Affiliation(s)
- I R Reid
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Auckland District Health Board, Auckland, New Zealand
| | - A M Horne
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - B Mihov
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A Stewart
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - E Garratt
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - K R Wiessing
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - M J Bolland
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - S Bastin
- Auckland District Health Board, Auckland, New Zealand
| | - G D Gamble
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Tan J, Sano H, Poole K. Antiresorptive-associated spontaneous fractures of both tibiae, followed by an atypical femur fracture during the sequential treatment with alendronate, denosumab then teriparatide. BMJ Case Rep 2019; 12:12/7/e229366. [PMID: 31340943 PMCID: PMC6663157 DOI: 10.1136/bcr-2019-229366] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
A 35-year-old man with juvenile idiopathic arthritis since childhood presented with bilateral atypical tibial fractures, followed by a later, single atypical fracture of the femur. The fractures were associated with 6 years of oral alendronate treatment immediately followed by subcutaneous denosumab therapy and later teriparatide therapy for osteoporosis. Atypical fractures are known to occur in the femur following bisphosphonate therapy; however, there are only a few documented cases of atypical fractures in the tibia. Our case highlights a rare but serious complication of a commonly prescribed antiresorptive agent. It also shows that teriparatide, while helpful in increasing bone mass, does not fully prevent the development of atypical fractures. Careful investigation should be considered in patients on long-term antiresorptive therapy presenting with bony tenderness to exclude an atypical fracture.
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Affiliation(s)
- Juan Tan
- Department of Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Hiroshige Sano
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Kenneth Poole
- Metabolic Bone Disease Unit, Addenbrooke's Hospital, Cambridge, UK
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Kleber M, Ntanasis-Stathopoulos I, Dimopoulos MA, Terpos E. Monoclonal antibodies against RANKL and sclerostin for myeloma-related bone disease: can they change the standard of care? Expert Rev Hematol 2019; 12:651-663. [PMID: 31268745 DOI: 10.1080/17474086.2019.1640115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Over 80% of the patients with multiple myeloma (MM) develop myeloma bone disease (MBD) during the disease course. The clinical consequences include serious skeletal-related events (SRE) that impact survival and quality of life. Bisphosphonates are the mainstay in the treatment of MBD. Currently, new therapeutic strategies are being introduced and broaden the therapeutic options in MBD. Areas covered: The purpose of this review is to summarize the current clinical management of MBD and present novel data regarding monoclonal antibodies against the receptor activator of NF-kappa B ligand (RANKL) and sclerostin that may change the clinical practice. Expert opinion: Our better understanding of the pathophysiology of MBD has identified several factors as potential therapeutic targets. Recent data have shown that the RANKL inhibitor denosumab constitutes a new promising option. The non-inferiority compared with bisphosphonates in terms of SRE prevention, the potential survival benefit, the convenience of subcutaneous administration, and the favorable toxicity profile makes denosumab a valuable alternative for physicians in the current treatment of MBD. Anti-sclerostin antibodies are currently under clinical development. Further investigations are needed to address open questions in the field including the value of anabolic agents combined with anti-resorptive and anti-MM drugs in MBD.
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Affiliation(s)
- Martina Kleber
- a Division of Hematology, Department of Medicine, University Hospital Basel , Basel , Switzerland.,b Division of Internal Medicine, Department of Medicine, University Hospital Basel , Basel , Switzerland
| | - Ioannis Ntanasis-Stathopoulos
- c Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens , Athens , Greece
| | - Meletios A Dimopoulos
- c Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens , Athens , Greece
| | - Evangelos Terpos
- c Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens , Athens , Greece
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Fink HA, MacDonald R, Forte ML, Rosebush CE, Ensrud KE, Schousboe JT, Nelson VA, Ullman K, Butler M, Olson CM, Taylor BC, Brasure M, Wilt TJ. Long-Term Drug Therapy and Drug Discontinuations and Holidays for Osteoporosis Fracture Prevention: A Systematic Review. Ann Intern Med 2019; 171:37-50. [PMID: 31009947 DOI: 10.7326/m19-0533] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Optimal long-term osteoporosis drug treatment (ODT) is uncertain. PURPOSE To summarize the effects of long-term ODT and ODT discontinuation and holidays. DATA SOURCES Electronic bibliographic databases (January 1995 to October 2018) and systematic review bibliographies. STUDY SELECTION 48 studies that enrolled men or postmenopausal women aged 50 years or older who were being investigated or treated for fracture prevention, compared long-term ODT (>3 years) versus control or ODT continuation versus discontinuation, reported incident fractures (for trials) or harms (for trials and observational studies), and had low or medium risk of bias (ROB). DATA EXTRACTION Two reviewers independently rated ROB and strength of evidence (SOE). One extracted data; another verified accuracy. DATA SYNTHESIS Thirty-five trials (9 unique studies) and 13 observational studies (11 unique studies) had low or medium ROB. In women with osteoporosis, 4 years of alendronate reduced clinical fractures (hazard ratio [HR], 0.64 [95% CI, 0.50 to 0.82]) and radiographic vertebral fractures (both moderate SOE), whereas 4 years of raloxifene reduced vertebral but not nonvertebral fractures. In women with osteopenia or osteoporosis, 6 years of zoledronic acid reduced clinical fractures (HR, 0.73 [CI, 0.60 to 0.90]), including nonvertebral fractures (high SOE) and clinical vertebral fractures (moderate SOE). Long-term bisphosphonates increased risk for 2 rare harms: atypical femoral fractures (low SOE) and osteonecrosis of the jaw (mostly low SOE). In women with unspecified osteoporosis status, 5 to 7 years of hormone therapy reduced clinical fractures (high SOE), including hip fractures (moderate SOE), but increased serious harms. After 3 to 5 years of treatment, bisphosphonate continuation versus discontinuation reduced radiographic vertebral fractures (zoledronic acid; low SOE) and clinical vertebral fractures (alendronate; moderate SOE) but not nonvertebral fractures (low SOE). LIMITATION No trials studied men, clinical fracture data were sparse, methods for estimating harms were heterogeneous, and no trials compared sequential treatments or different durations of drug holidays. CONCLUSION Long-term alendronate and zoledronic acid therapies reduce fracture risk in women with osteoporosis. Long-term bisphosphonate treatment may increase risk for rare adverse events, and continuing treatment beyond 3 to 5 years may reduce risk for vertebral fractures. Long-term hormone therapy reduces hip fracture risks but has serious harms. PRIMARY FUNDING SOURCE National Institutes of Health and Agency for Healthcare Research and Quality. (PROSPERO: CRD42018087006).
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Affiliation(s)
- Howard A Fink
- University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota (H.A.F., R.M., K.E.E., K.U., B.C.T., T.J.W.)
| | - Roderick MacDonald
- University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota (H.A.F., R.M., K.E.E., K.U., B.C.T., T.J.W.)
| | - Mary L Forte
- University of Minnesota, Minneapolis, Minnesota (M.L.F., C.E.R., V.A.N., M.B., C.M.O., M.B.)
| | - Christina E Rosebush
- University of Minnesota, Minneapolis, Minnesota (M.L.F., C.E.R., V.A.N., M.B., C.M.O., M.B.)
| | - Kristine E Ensrud
- University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota (H.A.F., R.M., K.E.E., K.U., B.C.T., T.J.W.)
| | - John T Schousboe
- University of Minnesota, Minneapolis, and HealthPartners, Bloomington, Minnesota (J.T.S.)
| | - Victoria A Nelson
- University of Minnesota, Minneapolis, Minnesota (M.L.F., C.E.R., V.A.N., M.B., C.M.O., M.B.)
| | - Kristen Ullman
- University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota (H.A.F., R.M., K.E.E., K.U., B.C.T., T.J.W.)
| | - Mary Butler
- University of Minnesota, Minneapolis, Minnesota (M.L.F., C.E.R., V.A.N., M.B., C.M.O., M.B.)
| | - Carin M Olson
- University of Minnesota, Minneapolis, Minnesota (M.L.F., C.E.R., V.A.N., M.B., C.M.O., M.B.)
| | - Brent C Taylor
- University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota (H.A.F., R.M., K.E.E., K.U., B.C.T., T.J.W.)
| | - Michelle Brasure
- University of Minnesota, Minneapolis, Minnesota (M.L.F., C.E.R., V.A.N., M.B., C.M.O., M.B.)
| | - Timothy J Wilt
- University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota (H.A.F., R.M., K.E.E., K.U., B.C.T., T.J.W.)
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Bover J, Ureña-Torres P, Laiz Alonso AM, Torregrosa JV, Rodríguez-García M, Castro-Alonso C, Górriz JL, Benito S, López-Báez V, Lloret Cora MJ, Cigarrán S, DaSilva I, Sánchez-Bayá M, Mateu Escudero S, Guirado L, Cannata-Andía J. Osteoporosis, densidad mineral ósea y complejo CKD-MBD (II): implicaciones terapéuticas. Nefrologia 2019; 39:227-242. [DOI: 10.1016/j.nefro.2018.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 09/13/2018] [Accepted: 10/31/2018] [Indexed: 12/23/2022] Open
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Kim TY, Bauer DC, McNabb BL, Schafer AL, Cosman F, Black DM, Eastell R. Comparison of BMD Changes and Bone Formation Marker Levels 3 Years After Bisphosphonate Discontinuation: FLEX and HORIZON-PFT Extension I Trials. J Bone Miner Res 2019; 34:810-816. [PMID: 30536713 PMCID: PMC10463267 DOI: 10.1002/jbmr.3654] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/26/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022]
Abstract
An ASBMR Task Force recommends a drug holiday for certain women treated for ≥5 years with oral alendronate or ≥3 years with intravenous zoledronic acid, with reassessment 2 to 3 years later. It is not known whether changes in bone mineral density (BMD) or bone turnover markers differ after oral or intravenous therapy. Our goal was to compare changes in BMD and procollagen type I N propeptide (PINP) after oral or intravenous bisphosphonate use. In the Fracture Intervention Trial Long-term Extension (FLEX), women who received a mean 5 years of alendronate were randomized to placebo or continued treatment. In the Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly-Pivotal Fracture Trial Extension I (HORIZON-PFT E1), women who received 3 years of zoledronic acid were randomized to placebo or continued treatment. We examined the proportion of participants with BMD loss or PINP gain ≥ least significant change (LSC) and those whose values exceeded a threshold (T-score ≤-2.5 or PINP ≥36.0 ng/mL, a premenopausal median value). After 3 years of placebo, the FLEX group had greater mean total hip BMD decreases (-2.3% versus -1.2% in the HORIZON-PFT E1 group, p < 0.01) and greater rises in PINP (+11.6 ng/mL versus +6.7 ng/mL, p < 0.01). There was a greater proportion of individuals in FLEX with total hip BMD loss and PINP increases that exceeded LSC, and PINP values ≥36.0 ng/mL. In contrast, there were small changes in the proportion of women with femoral neck T-scores ≤-2.5 in both groups. In conclusion, 3 years after bisphosphonate discontinuation, a considerable proportion of former alendronate and zoledronic acid users had meaningful declines in total hip BMD and elevations in PINP. Despite a longer treatment course, alendronate may have a more rapid offset of drug effect than zoledronic acid. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Tiffany Y Kim
- Department of Medicine, University of California, San Francisco, CA, USA
- Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Douglas C Bauer
- Department of Medicine, University of California, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Brian L McNabb
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Anne L Schafer
- Department of Medicine, University of California, San Francisco, CA, USA
- Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Felicia Cosman
- Department of Clinical Medicine, Columbia University, New York, NY, USA
- Clinical Research Center, Helen Hayes Hospital, West Haverstraw, NY, USA
| | - Dennis M Black
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Richard Eastell
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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40
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Black DM, Abrahamsen B, Bouxsein ML, Einhorn T, Napoli N. Atypical Femur Fractures: Review of Epidemiology, Relationship to Bisphosphonates, Prevention, and Clinical Management. Endocr Rev 2019; 40:333-368. [PMID: 30169557 DOI: 10.1210/er.2018-00001] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 05/08/2018] [Indexed: 12/18/2022]
Abstract
Bisphosphonates (BPs) are highly effective in treating osteoporosis and reducing hip, vertebral, and other fractures by as much as 50% to 70%. However, since 2006, atypical femur fractures (AFFs) emerged as potential side effects of BPs and other treatments. These fractures have unusual radiologic features and occur with little trauma. Public concern has led to a >50% decrease in BP usage. AFFs are rare: for each AFF, >1200 fractures, including 135 hip fractures, are prevented. Case definition criteria were updated by the American Society of Bone and Mineral Research in 2014. Many epidemiologic studies have been reported, and although methodologically challenging, generally support a BP-AFF association. However, the magnitude of the association between BPs and AFFs is uncertain: estimates of relative risk for AFFs among BP users vs nonusers range from 1 to 65 with a meta-analysis estimate of 1.7. Although mechanistic studies have proposed several hypotheses explaining how BPs might decrease bone strength, AFF pathogenesis remains uncertain and cannot explain the paradox of efficacy of reduction of common fractures while increasing risk for rare fractures at one site. There are several consistent risk factors, including Asian race (in North America), femoral bowing, and glucocorticoid use, whereas others remain unclear. Consensus is emerging about strategies to prevent AFFs in BP users (including drug holidays after 5 years' use in some patients). In conclusion, AFFs can be devastating, but even under the most pessimistic assumptions, the benefit/risk ratio is highly positive for BPs, particularly during 3 to 5 years of use. As understanding of AFFs increases, it is becoming increasingly possible to maximize BP benefits while minimizing AFF risk.
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Affiliation(s)
- Dennis M Black
- University of California, San Francisco, San Francisco, California
| | | | | | | | - Nicola Napoli
- Università Campus Bio-Medico di Roma, Rome, Italy.,IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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41
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Mailoo VJ, Srinivas V, Turner J, Fraser WD. Beware of bone pain with bisphosphonates. BMJ Case Rep 2019; 12:12/3/e225385. [PMID: 30872334 DOI: 10.1136/bcr-2018-225385] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 71-year-old woman who had been taking ibandronate for 10 years presented to an Endocrinology Department with persistent mid-thigh pain. Pelvic X-ray showed bilateral femoral cortical expansion, indicating impending atypical femoral fractures (AFFs). AFFs have been linked to long-term bisphosphonate therapy and have morbidity and mortality similar to that of hip fractures. Such fractures can be averted by regular reviews of bisphosphonate therapy and vigilance for prodromal symptoms. This patient's bisphosphonate therapy was stopped, and fractures were avoided by treatment with vitamin D and parathyroid hormone.
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Affiliation(s)
| | - Vidya Srinivas
- Diabetes and Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Jeremy Turner
- Diabetes and Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - William Duncan Fraser
- Diabetes and Endocrinology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Medical School, Norwich Research Park, University of East Anglia, Norwich, UK
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42
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Popp KL, Caksa S, Martinez-Betancourt A, Yuan A, Tsai J, Yu EW, Bouxsein ML. Cortical Bone Material Strength Index and Bone Microarchitecture in Postmenopausal Women With Atypical Femoral Fractures. J Bone Miner Res 2019; 34:75-82. [PMID: 30281863 DOI: 10.1002/jbmr.3590] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 09/05/2018] [Accepted: 09/18/2018] [Indexed: 01/19/2023]
Abstract
Atypical femoral fractures are rare fractures that occur in the subtrochanteric or diaphyseal region of the femur with minimal or no trauma. Though the association of atypical femoral fractures (AFFs) and bisphosphonate (BP) use is a growing concern in the management of osteoporosis, currently there is little knowledge about which patients may be at risk for an atypical femoral fracture. Given that these fractures initiate in the femoral cortex, we aimed to determine whether cortical bone tissue properties (bone material strength index; BMSi), as measured by in vivo impact microindentation, are altered in atypical fracture patients. We also aimed to identify factors associated with the BMSi measurements. We enrolled postmenopausal women with recent AFFs (n = 15) or hip fractures (Hip Fxs; n = 20), long-term (>5 years) BP users (n = 30), and treatment naïve controls (n = 88). We measured total hip and femoral neck BMD by DXA, cortical bone microstructure at the distal tibia by HR-pQCT, and BMSi at the midtibia by impact microindentation. BMSi values were similar in all groups, with no effects of long-term BP use or lower values in patients with AFFs or Hip Fxs, even after multivariable adjustment. BMSi measurements were independent of age, femoral BMD, duration of BP treatment, vitamin D level, and cortical bone microstructure, including cortical porosity and cortical tissue mineral density. In conclusion, impact microindentation values are not negatively affected by long-term BP use and do not appear to discriminate individuals who suffer AFFs. Thus, our results do not support clinical use of impact microindentation to identify those at risk for AFFs. This remains to be verified in larger studies. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, THR-1051, Boston, MA USA
| | - Signe Caksa
- Endocrine Unit, Massachusetts General Hospital, 50 Blossom Street, THR-1051, Boston, MA USA
| | | | - Amy Yuan
- Endocrine Unit, Massachusetts General Hospital, 50 Blossom Street, THR-1051, Boston, MA USA
| | - Joy Tsai
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, THR-1051, Boston, MA USA
| | - Elaine W Yu
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, THR-1051, Boston, MA USA
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, THR-1051, Boston, MA USA.,Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, and Department of Orthopedic Surgery, Harvard Medical School, One Overland Street, Boston, MA USA
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43
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Abstract
Atypical femur fractures associated with long-term bisphosphonate use can be challenging injuries to manage. Not only do they have a prolonged healing time and increased rate of nonunion as compared to typical femur fractures, intraoperative complications are not infrequent and can be catastrophic. Given the pathologic nature of these fractures, a multidisciplinary approach to the patient's care is necessary. Treatment begins with medical optimization and careful surgical planning. Radiographic characteristics of the fracture and femoral osteology dictate reduction strategy, adjunctive surgical techniques, and implant choice. Intraoperative complications including malreduction, iatrogenic fracture, and fracture propagation can be avoided with thoughtful planning. The purpose of this article is to discuss the technical aspects of surgical management of atypical femur fractures. We also discuss management of intraoperative complications and treatment failure. Finally, we provide an update on recommendations for postoperative medical treatment and management of the contralateral femur.
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Myeloma Bone Disease: Update on Pathogenesis and Novel Treatment Strategies. Pharmaceutics 2018; 10:pharmaceutics10040202. [PMID: 30355994 PMCID: PMC6321035 DOI: 10.3390/pharmaceutics10040202] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/15/2018] [Accepted: 10/20/2018] [Indexed: 01/31/2023] Open
Abstract
Bone disease, including osteolytic lesions and/or osteoporosis, is a common feature of multiple myeloma (MM). The consequences of skeletal involvement are severe pain, spinal cord compressions, and bone fractures, which have a dramatic impact on patients’ quality of life and, ultimately, survival. During the past few years, several landmark studies significantly enhanced our insight into MM bone disease (MBD) by identifying molecular mechanisms leading to increased bone resorption due to osteoclast activation, and decreased bone formation by osteoblast inhibition. Bisphosphonates were the mainstay to prevent skeletal-related events in MM for almost two decades. Excitingly, the most recent approval of the receptor activator of NF-kappa B ligand (RANKL) inhibitor, denosumab, expanded treatment options for MBD, for patients with compromised renal function, in particular. In addition, several other bone-targeting agents, including bone anabolic drugs, are currently in preclinical and early clinical assessment. This review summarizes our up-to-date knowledge on the pathogenesis of MBD and discusses novel state-of-the-art treatment strategies that are likely to enter clinical practice in the near future.
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45
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Alarkawi D, Ali MS, Bliuc D, Center JR, Prieto‐Alhambra D. The Challenges and Opportunities of Pharmacoepidemiology in Bone Diseases. JBMR Plus 2018; 2:187-194. [PMID: 30283902 PMCID: PMC6124176 DOI: 10.1002/jbm4.10051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/21/2018] [Accepted: 03/27/2018] [Indexed: 11/29/2022] Open
Abstract
Pharmacoepidemiology is used extensively in osteoporosis research and involves the study of the use and effects of drugs in large numbers of people. Randomized controlled trials are considered the gold standard in assessing treatment efficacy and safety. However, their results can have limited external validity when applied to day-to-day patients. Pharmacoepidemiological studies aim to assess the effect/s of treatments in actual practice conditions, but they are limited by the quality, completeness, and inherent bias due to confounding. Sources of information include prospectively collected (primary) as well as readily available routinely collected (secondary) (eg, electronic medical records, administrative/claims databases) data. Although the former enable the collection of ad hoc measurements, the latter provide a unique opportunity for the study of large representative populations and for the assessment of rare events at relatively low cost. Observational cohort and case-control studies, the most commonly implemented study designs in pharmacoepidemiology, each have their strengths and limitations. However, the choice of the study design depends on the research question that needs to be answered. Despite the many advantages of observational studies, they also have limitations. First, missing data is a common issue in routine data, frequently dealt with using multiple imputation. Second, confounding by indication arises because of the lack of randomization; multivariable regression and more specific techniques such as propensity scores (adjustment, matching, stratification, trimming, or weighting) are used to minimize such biases. In addition, immortal time bias (time period during which a subject is artefactually event-free by study design) and time-varying confounding (patient characteristics changing over time) are other types of biases usually accounted for using time-dependent modeling. Finally, residual "uncontrolled" confounding is difficult to assess, and hence to account for it, sensitivity analyses and specific methods (eg, instrumental variables) should be considered.
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Affiliation(s)
- Dunia Alarkawi
- Bone Biology DivisionGarvan Institute of Medical ResearchSchool of MedicineUniversity of New South WalesSydneyAustralia
| | - M Sanni Ali
- Centre for Statistics in Medicine and Nuffield Department of OrthopaedicsRheumatologyand Musculoskeletal Sciences (NDORMS)University of OxfordOxfordUK
| | - Dana Bliuc
- Bone Biology DivisionGarvan Institute of Medical ResearchSchool of MedicineUniversity of New South WalesSydneyAustralia
| | - Jacqueline R Center
- Bone Biology DivisionGarvan Institute of Medical ResearchSchool of MedicineUniversity of New South WalesSydneyAustralia
- Clinical SchoolSt Vincent's HospitalSydneyAustralia
| | - Daniel Prieto‐Alhambra
- Centre for Statistics in Medicine and Nuffield Department of OrthopaedicsRheumatologyand Musculoskeletal Sciences (NDORMS)University of OxfordOxfordUK
- MRC Lifecourse Epidemiology UnitSouthamptonUK
- GREMPAL Research Group (Idiap Jordi Gol Primary Care Research Institute) and CIBERFesUniversitat Autonoma de BarcelonaBarcelonaSpain
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46
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Dell R, Greene D. A proposal for an atypical femur fracture treatment and prevention clinical practice guideline. Osteoporos Int 2018; 29:1277-1283. [PMID: 29675745 DOI: 10.1007/s00198-018-4506-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 03/23/2018] [Indexed: 01/27/2023]
Abstract
UNLABELLED The prevention as well as the treatment of atypical femur fractures (AFFs) remains controversial but there have been many clinical recommendations suggested. We have summarized these recommendations as well as expanded upon them in this paper. INTRODUCTION The purpose of the paper was to develop a clinical practice guideline that both treats AFF and decreases the risk of AFF in patients requiring antiresorptive medications. Examples of these medications include bisphosphonates and denosumab for the treatment of osteoporosis. METHODS A literature review looking for recommendations on AFF identification, management, and prevention was done. We also performed an updated review of clinical guidelines on AFF prevention and treatment that were developed for the Kaiser Permanente osteoporosis/fracture prevention team. RESULTS Concise clinical practice guidelines are presented that can be applied in treatment of AFF as well as help reduce the risk of developing an AFF in patients requiring antiresorptive medications. These guidelines are based on using both typical fracture and AFF risk assessment to determine duration of antiresorptive of 3 to 5 years before consideration if a drug holiday is needed. Specific groups such as younger Asian women should be reassessed at 3 years with DXA and FRAX to see if a drug holiday is needed whereas patients at higher risk for typical fractures may be reassessed at 5 years of treatment. The DXA rescreening can now be accessed if focal or generalized lateral cortex changes are present that may indicate incomplete AFFs are present. If an incomplete AFF is discovered either by DXA or by other imaging studies, it is imperative to stop antiresorptive medications and to take additional measures to lower the risk of progression to a complete AFF. If complete AFF does occur, then antiresorptive medications should be stopped and additional measures should be taken to decrease the risk of developing an AFF on the contralateral femur. CONCLUSIONS Clinical practice guidelines for the treatment and prevention of AFF will benefit clinicians who are frequently faced with having to make clinical decisions in patients requiring antiresorptive medications.
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Affiliation(s)
- R Dell
- Kaiser Downey Southern California, 9353 Imperial Hwy, Downey, CA, 90242, USA.
| | - D Greene
- Kaiser Downey Southern California, 9353 Imperial Hwy, Downey, CA, 90242, USA
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47
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Naylor KE, Bradburn M, Paggiosi MA, Gossiel F, Peel NFA, McCloskey EV, Walsh JS, Eastell R. Effects of discontinuing oral bisphosphonate treatments for postmenopausal osteoporosis on bone turnover markers and bone density. Osteoporos Int 2018. [PMID: 29525970 DOI: 10.1007/s00198-018-4460-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
UNLABELLED The antiresorptive potency varies between different bisphosphonates. We investigated the effect of stopping oral bisphosphonate treatment for postmenopausal osteoporosis (ibandronate, alendronate, risedronate) on BTMs and BMD. After stopping treatment, all three groups showed an increase in BTMs and a decrease in hip BMD; however, none returned to pre-treatment baseline values. INTRODUCTION Bisphosphonates (BPs) continue to suppress bone turnover markers (BTMs) after treatment has stopped, leading to the suggestion that a pause in treatment could be considered for low-risk patients. Indirect comparisons suggest that after cessation of treatment, the effects on bone may differ between drugs. We investigated the effects of stopping oral BP treatments for postmenopausal osteoporosis on BTMs and bone mineral density (BMD). METHODS We studied postmenopausal osteoporotic women who had previously taken part in a 2-year randomised study of three oral BPs (ibandronate, alendronate, or risedronate). At the end of the study, women with hip BMD T-score > - 2.5 and considered clinically appropriate to discontinue treatment were invited to participate in a further 2-year observational study. Biochemical response was assessed using BTMs, and BMD was measured by dual-energy X-ray absorptiometry. RESULTS All BTMs increased after treatment withdrawal but remained below the pre-treatment baseline with less suppression of BTMs for the risedronate group compared to alendronate and ibandronate up to 48 weeks. There was no difference between the BP groups 96 weeks after stopping treatment. The change in BMD during the 96 weeks after stopping treatment was - 1.6% (95% CI - 1.9 to - 1.2, P < 0.001) for the total hip and - 0.6% (95% CI - 1.1 to - 0.2, P = 0.17) at the lumbar spine with no difference between the three BP groups (P = 0.85 and P = 0.48, respectively). CONCLUSION For all treatment groups, there was an increase in BTMs and a decrease in hip BMD after stopping BPs for 2 years; however, none returned to pre-treatment baseline values.
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Affiliation(s)
- K E Naylor
- Academic Unit of Bone Metabolism, The Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK.
| | - M Bradburn
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - M A Paggiosi
- Academic Unit of Bone Metabolism, The Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - F Gossiel
- Academic Unit of Bone Metabolism, The Mellanby Centre for Bone 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
| | - E V McCloskey
- Academic Unit of Bone Metabolism, The Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
- Centre for Integrated Research into Musculoskeletal Ageing, Sheffield, UK
| | - J S Walsh
- 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
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48
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Vargas-Franco JW, Castaneda B, Rédiní F, Gómez DF, Heymann D, Lézot F. Paradoxical side effects of bisphosphonates on the skeleton: What do we know and what can we do? J Cell Physiol 2018; 233:5696-5715. [PMID: 29323712 DOI: 10.1002/jcp.26465] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/05/2018] [Indexed: 12/15/2022]
Abstract
Bisphosphonates are considered the most effective drugs for controlling adult and pediatric osteolytic diseases. Although they have been used successfully for many years, several side effects, such as osteonecrosis of the jaw, delayed dental eruption, atypical femoral fracture, and alterations to the bone growth system, have been described. After an overview of nitrogenous bisphosphonate, the purpose of this article is to describe their mechanisms of action and current applications, review the preclinical and clinical evidence of their side effects in the skeleton ("what we know"), and describe current recommendations for preventing and managing these effects ("what we can do"). Finally, promising future directions on how to limit the occurrence of these side effects will be presented.
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Affiliation(s)
- Jorge W Vargas-Franco
- UMR-1238, INSERM, Equipe 1, Faculté de Médecine de l'Université de Nantes, Nantes, France.,Department of Basic Studies, Faculty of Odontology, University of Antioquia, Medellin, Colombia
| | - Beatriz Castaneda
- INSERM, UMR-1138, Equipe 5, Centre de Recherche des Cordeliers, Paris, France
| | - Françoise Rédiní
- UMR-1238, INSERM, Equipe 1, Faculté de Médecine de l'Université de Nantes, Nantes, France
| | - David F Gómez
- Department of Basic Studies, Faculty of Odontology, University of Antioquia, Medellin, Colombia
| | - Dominique Heymann
- INSERM, LEA Sarcoma Research Unit, Department of Oncology and Human Metabolism, Medical School, University of Sheffield, Sheffield, UK.,UMR-1232, Institut de Cancérologie de l'Ouest, Site René Gauducheau, INSERM, Boulevard Professeur Jacques Monod, Saint-Herblain, France
| | - Frédéric Lézot
- UMR-1238, INSERM, Equipe 1, Faculté de Médecine de l'Université de Nantes, Nantes, France
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49
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Kinoshita M, Ishijima M, Kaneko H, Liu L, Nagao M, Sadatsuki R, Hada S, Arita H, Aoki T, Yamanaka M, Nojiri H, Sakamoto Y, Tokita A, Kaneko K. The increase in bone mineral density by bisphosphonate with active vitamin D analog is associated with the serum calcium level within the reference interval in postmenopausal osteoporosis. Mod Rheumatol 2018; 29:157-164. [PMID: 29451049 DOI: 10.1080/14397595.2018.1442671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To examine the factors associated with increase in lumbar spine bone mineral density (LS-BMD) by bisphosphonates (BPs) with active vitamin D analog (aVD). METHODS Two independent postmenopausal osteoporotic patients treated by BPs with aVD for 24 months (Study 1: n = 93, Study 2: n = 99) were retrospectively analyzed. RESULTS In Study 1, LS-BMD of the patients significantly increased for 24 m (5.4%, p < .001). A multiple regression analysis among baseline characteristics revealed that serum calcium (sCa: 8.5-10.5 mg/dL) was associated with an increased LS-BMD by treatment (r2: 0.088, p = .02). While average sCa of the patients was 9.2 mg/dL before treatment, it increased time-dependently to 9.6 mg/dL for 24 m by treatment. As each patient had their LS-BMD five times during the study, there were four instances of %LS-BMD in each patient, resulting in 372 instances of %LS-BMD in Study 1. The smallest Akaike's information criterion value for the most appropriate cut-off levels of sCa for %LS-BMD by treatment every 6 m was 9.3 mg/dL. The %LS-BMD by treatment for 6 m during 24 m period in patients with sCa ≥9.3 mg/dL (1.5%) was significantly higher than that in patients with sCa <9.3 mg/dL (0.8%, p = .038). The results of Study 2 were similar to those of Study 1, confirming the phenomena observed. CONCLUSION sCa was associated with an increased LS-BMD by BPs with aVD.
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Affiliation(s)
- Mayuko Kinoshita
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Muneaki Ishijima
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan.,b Sportology Center , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Haruka Kaneko
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Lizu Liu
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan.,b Sportology Center , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Masashi Nagao
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Ryo Sadatsuki
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Shinnosuke Hada
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Hitoshi Arita
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Takako Aoki
- b Sportology Center , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Makoto Yamanaka
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Hidetoshi Nojiri
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Yuko Sakamoto
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Akifumi Tokita
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan
| | - Kazuo Kaneko
- a Department of Medicine for Orthopedics and Motor Organ , Graduate School of Medicine, Juntendo University , Tokyo , Japan.,b Sportology Center , Graduate School of Medicine, Juntendo University , Tokyo , Japan
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50
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Lagari V, Gavcovich T, Levis S. The Good and the Bad About the 2017 American College of Physicians Osteoporosis Guidelines. Clin Ther 2018; 40:168-176. [DOI: 10.1016/j.clinthera.2017.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 11/14/2017] [Accepted: 11/14/2017] [Indexed: 01/06/2023]
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