Glucocorticoid-induced osteoporosis

Linagliptin-metformin combination: A novel approach to mitigate 4-vinyl cyclohexene di epoxide and dexamethasone-induced osteoporosis in mice

Elevated levels of dipeptidyl-peptidase (DPP-4) enzyme, associated with accelerated bone resorption, are linked to both post-menopausal osteoporosis (PMO) and glucocorticoid-induced osteoporosis (GIO). Consequently, DPP-4 inhibitors, a class of anti-diabetic drugs, emerge as potential candidates for repurposing as anti-osteoporotic agents. In this study, we explored the effect of 4-week treatment with linagliptin (a DPP-4 inhibitor) and its combination with metformin on PMO and GIO in mice. PMO was induced in Balb/c mice by injecting 4-vinyl cyclohexene diepoxide (VCD), 160 mg/kg, ip for 15 days while GIO was induced by administering dexamethasone (DEX) 5 mg/kg, ip for 21 days. A significant improvement in bone architectural parameters and bone mineral density (BMD) was observed following the linagliptin-metformin combination, which was consistent with the altered bone turnover markers i.e., increased ALP, osteocalcin, BMP-2, and reduced serum calcium, TRAP, sclerostin and pro-inflammatory cytokines. Results from bone immunohistochemistry (IHC) demonstrated that the combination led to an increase in immunopositive OPG cells, while RANKL expression was diminished. Linagliptin, however, demonstrated only partial improvement in the PMO model. Conversely, in the GIO model, linagliptin did not show a significant effect except for improved BMD and sclerostin levels. Treatment with metformin did not show significant changes in either model. These findings suggest that the combination of linagliptin with metformin could alleviate the PMO and GIO, possibly through targeting AMPK and Wnt signaling pathway and thereby modulating BMP-2, sclerostin and RANKL/OPG.

Validation of an osteoporosis self-assessment tool for Vietnamese postmenopausal women and men over 50 years

INTRODUCTION

The aim of this study was to validate the effectiveness of the osteoporosis self-assessment tool for Asians (OSTA) in the screening and diagnosis of osteoporosis in men aged over 50 years and postmenopausal women in the northern Vietnam population.

MATERIALS AND METHODS

This study included 8077 participants (7044 postmenopausal women and 1033 men aged over 50) who attended health examinations at the National Institute of Nutrition, Vietnam, from 2010-2019. Osteoporosis is defined by a T-score ≤ -2.5 at the femoral neck, total hip, or L1-L4. OSTA scores were assessed for identifying osteoporosis via receiver operating characteristic (ROC) curves. The optimal cut-off points, sensitivity, specificity, and areas under the ROC curves (AUCs) were determined.

RESULTS

The study showed that the prevalence of osteoporosis was 13.4% in men and 25.5% in women. In women, a higher BMI and OSTA scores decreased the OR of osteoporosis (all p-values < 0.001). In men, a higher BMI decreased the OR of osteoporosis (p-value < 0.001). The results showed that the OSTA value was -1 which had a sensitivity of over 70% in both men and women. The OSTA value was -4 which had a sensitivity of over 90% and specificity of over 80% in both men and women. The optimal OSTA value was -3 which had a sensitivity of over 90% and a specificity of over 80% in both men and women.

CONCLUSIONS

The OSTA might be a simple tool for the screening and diagnosis of osteoporosis in Vietnamese postmenopausal women and men aged over 50 years.

Association between urinary catecholamines and glucocorticoids and bone mineral density and osteoporosis in Puerto Rican adults

Chronic stress leads to elevated stress hormones, which may be linked to bone breakdown. Puerto Rican adults living on the US mainland have higher prevalence of stress than the general population, and higher and/or similar prevalence of osteoporosis compared with non-Hispanic Whites. The role of stress on bone remains unclear and may be modified by diet. A Dietary Approaches to Stop Hypertension (DASH) pattern, as a measure of dietary quality, was most protective for bone outcomes among Puerto Ricans. In this cross-sectional study, 958 Boston Puerto Rican Health Study participants were included (aged: 59.9 ± 7.6 yr). Stress markers (epinephrine, norepinephrine, cortisol) were collected via 12-h urine samples and elevated concentrations were categorized using sex-specific cutoffs. BMD was assessed via DXA. Analysis of covariance models with least squares means were used to test differences in mean BMD between participants with elevated and non-elevated stress markers. Multivariable logistic regression examined associations between stress markers and osteoporosis in postmenopausal females and males. Models were adjusted for age, height, smoking, alcohol use, education, glucocorticoid use, and diabetes. Higher urinary epinephrine was associated with lower BMD at the LS (p = .012), FN (p = .005), trochanter (p < .001), and TH (p < .001) in Puerto Rican adults, and with higher odds of osteoporosis among males (odds ratio = 4.01 [95%CI: 1.11, 14.5], p = .03). An interaction between DASH and norepinephrine was noted for postmenopausal females at the LS. No associations were noted for norepinephrine or cortisol (p > .11), although higher urinary norepinephrine was associated with lower LS BMD in postmenopausal females not taking estrogen, with lower adherence to DASH (p = .03). Higher urinary epinephrine and norepinephrine were associated with poorer bone outcomes in Puerto Rican adults, in a sex-specific manner, warranting future longitudinal studies to clarify associations. Dietary quality may moderate these associations.

Development of a macrophage polarization-modulating therapeutic agent for osteoarthritis treatment

Osteoarthritis (OA) is a common chronic degenerative joint disease. Recent studies have emphasized the crucial role of macrophages, particularly tissue-resident macrophages (Tissue-Resident Macrophages, TRMs), in the pathogenesis and progression of OA. Under physiological conditions, TRMs maintain joint homeostasis, but under various stimuli, they can polarize into pro-inflammatory M1 or anti-inflammatory M2 phenotypes. An imbalance in macrophage polarization, favoring the M1 phenotype, leads to sustained inflammation, cartilage degradation, and osteophyte formation, further exacerbating OA symptoms and structural damage. This article reviews the current understanding of macrophage polarization in OA, with a particular emphasis on the mechanisms by which TRMs influence the joint microenvironment. It explores the therapeutic potential of drug molecular platforms aimed at regulating macrophage polarization, shifting the balance from pro-inflammatory M1 to anti-inflammatory M2. The discussion includes various pharmacological agents such as corticosteroids, hyaluronic acid derivatives, monoclonal antibodies, and bioactive molecules like Squid Type II Collagen (SCII) in modulating macrophage function and slowing OA progression. Additionally, the article examines advancements in gene therapy methods targeting macrophages, utilizing nanotechnology-based delivery systems to enhance the specificity and efficiency of macrophage phenotype regulation. Targeting TRMs through sophisticated drug molecular platforms presents a promising strategy for developing novel diagnostic and therapeutic interventions for osteoarthritis.

Total Femoral Head Collapse in a Corticosteroid-Induced Pathologic Fracture

Glucocorticoid therapy is a well-established iatrogenic cause of secondary osteoporosis. This form of osteoporosis is known as glucocorticoid-induced osteoporosis (GIOP). We present the case of a 78-year-old woman who developed avascular necrosis and complete collapse of the femoral head after a high-dose steroid taper for asthma. Imaging showed subsequent femoral head collapse with the presence of protrusio acetabuli. The patient underwent a posterior total hip arthroplasty. This case is unique because of the extremely high dose of steroids and the timing of her fracture. The case reveals the adverse effects of prolonged glucocorticoid use on bone health, showing the need for proper preventive measures such as bone density scans and proper supplementation if needed. Using anti-osteoporotic medications such as bisphosphonates or denosumab can mitigate the occurrence of GIOP. Early recognition and proper management are critical in decreasing the incidence of GIOP-related fractures.

["Paradoxical fractures": pathological fractures under anti-osteoporotic and antirheumatic treatment]

Pathological fractures under anti-osteoporotic and antirheumatic treatment are very rare events. Nevertheless, atypical femoral fractures occur during antiresorptive treatment with bisphosphonates or denosumab, the latter especially in patients previously treated with bisphosphonates. Treatment with teriparatide can be helpful. While glucocorticoids have a well-known influence on the development of osteoporosis and thus also fractures, the probably unproblematic use in the low-dose range has so far found little acceptance. Methotrexate-induced osteopathy is also a rare phenomenon but is now well accepted and known. There are several approved medications for the treatment of glucocorticoid-induced osteoporosis and for methotrexate-induced osteopathy, discontinuation of methotrexate is particularly essential.

Glucocorticoids Alter Bone Microvascular Barrier via MAPK/Connexin43 Mechanisms

Glucocorticoids (GCs) are standard-of-care treatments for inflammatory and immune disorders, and their long-term use increases the risk of osteoporosis. Although GCs decrease bone functionality, their role in bone microvasculature is incompletely understood. Herein, the study investigates the mechanisms of bone microvascular barrier function via osteoblast-endothelial interactions in response to GCs. The animal data shows that prednisolone (Psl) downregulated the osteoblast function and microvessel number and size. To investigate the role of GCs in bone endothelial barrier function further, a bicellular microfluidic in vitro system is developed and utilized, which consists of three-dimensional (3D) perfusable microvascular structures embedded in collagen I/osteoblast matrix. Interestingly, it is demonstrated that GCs significantly inhibit osteogenesis and microvascular barrier function by interfering with endothelial-osteoblast interactions. This effect is triggered by MAPK-induced phosphorylation of connexin43 (Cx43) at Ser282. Collectively, this study sheds light on microvascular function in bone disorders, as osteoporosis, and permits to capture dynamic changes in endothelial-bone interactions under GCs by dissecting the MAPK/Cx43 mechanism and proposing this as a potential target for bone diseases.

Effects of Denosumab and Bisphosphonates on Glucocorticoid-induced Osteoporosis in Patients with Neuroimmunological Disorders

Objective Although patients with neuroimmunological disorders often need to be treated with glucocorticoids and are at risk of developing glucocorticoid-induced osteoporosis, no research has focused on the treatment of glucocorticoid-induced osteoporosis in such patients. Methods We compared the efficacy of denosumab and bisphosphonates in glucocorticoid-induced osteoporosis in neuroimmunological diseases. In 57 patients with neuroimmunological disorders treated with corticosteroids (34 with neuromyelitis optica spectrum disorders, 16 with myasthenia gravis, and 7 with others), we retrospectively studied the long-term effects of denosumab (n=23) and bisphosphonates (n=34) on spine and total hip bone mineral density (BMD) measured by dual energy X-ray absorptiometry. Results There were no significant differences in the age, lumbar spine BMD, or mean dose or duration of prednisolone administration at baseline between the denosumab and bisphosphonate groups. During the follow-up period of up to 6 years, the increase in the lumbar spine and total hip BMD was greater in the denosumab group than in the bisphosphonate group (p<0.01). Insufficient bone fractures were observed in 2 (9%) of the 23 patients in the denosumab group and in 2 (6%) of the 34 patients in the bisphosphonate group (not significant). Conclusion Denosumab is more effective than bisphosphonates in increasing the BMD of patients with neuroimmunological disorders receiving glucocorticoids.

Pathological fractures and the perils of purchasing steroids online

Exogenous steroids are a staple of modern medicine, with utility in a variety of direct and supplemental treatment modalities. However, all pharmaceuticals are undoubtedly coupled with unique side effect profiles, and steroids are no exception. In the case presented, the assessment and management of a 36-year-old male who inappropriately self-administered high-dose steroids for prolonged periods of time is reviewed. In doing so, attention is drawn to both the impact of glucocorticoid-induced osteoporosis and the greater risk of online availability of these powerful medications.

Metformin Modulates Cell Oxidative Stress to Mitigate Corticosteroid-Induced Suppression of Osteogenesis in a 3D Model

Background

Corticosteroids provide well-established therapeutic benefits; however, they are also accompanied by adverse effects on bone. Metformin is a widely used medication for managing type 2 diabetes mellitus. Recent studies have highlighted additional therapeutic benefits of metformin, particularly concerning bone health and oxidative stress.

Objective

This research investigates the effects of prednisolone on cellular metabolic functions and bone formation using a 3D in vitro model. Then, we demonstrate the potential therapeutic effects of metformin on oxidative stress and the formation of calcified matrix due to corticosteroids.

Methods

Human mesenchymal stem cells (MSCs) and macrophages were cultured in a 3D GelMA scaffold and stimulated with prednisolone, with and without metformin. The adverse effects of prednisolone and metformin's therapeutic effect(s) were assessed by analyzing cell viability, osteogenesis markers, bone mineralization, and inflammatory markers. Oxidative stress was measured by evaluating reactive oxygen species (ROS) levels and ATP production.

Results

Prednisolone exhibited cytotoxic effects, reducing the viability of MSCs and macrophages. Lower osteogenesis potential was also detected in the MSC group. Metformin positively affected cell functions, including enhanced osteoblast activity and increased bone mineralization. Furthermore, metformin effectively reduced oxidative stress, as evidenced by decreased ROS levels and increased ATP production. These findings indicate that metformin protects against oxidative damage, thus supporting osteogenesis.

Conclusion

Metformin exhibits promising therapeutic potential beyond its role in diabetes management. The capacity to alleviate oxidative stress highlights the potential of metformin in supporting bone formation in inflammatory environments.

Bone quality relies on hyaluronan synthesis - Insights from mice with complete knockout of hyaluronan synthase expression

Bone consists of a complex mineralised matrix that is maintained by a controlled equilibrium of synthesis and resorption by different cell types. Hyaluronan (HA) is an important glycosaminoglycan in many tissues including bone. Previously, the importance of HA synthesis for bone development during embryogenesis has been shown. We therefore investigated whether HA synthesis is involved in adult bone turnover and whether abrogation of HA synthesis in adult mice would alter bone quality. To achieve complete abrogation of HA synthesis in adult mice, we generated a novel Has-total knockout (Has-tKO) mouse model in which a constitutive knockout of Has1 and Has3 was combined with an inducible, Ubc-Cre-driven Has2 knockout. By comparing bone tissue from wild-type, Has1,3 double knockout and Has-tKO mice, we demonstrate that Has2-derived HA mainly contributes to the HA content in bone. Furthermore, Has-tKO mice show a significant decrease of bone integrity in trabecular and cortical bone, as shown by µ-CT analysis. These effects are detectable as early as five weeks after induced Has2 deletion, irrespective of sex and progress with age. Mesenchymal stem cells (MSC) during osteogenic differentiation in vitro showed that Has2 expression is increased while Has3 expression is decreased during differentiation. Furthermore, the complete abrogation of HA synthesis results in significantly reduced osteogenic differentiation as indicated by reduced marker gene expression (Runx-2, Tnalp, Osterix) as well as alizarin red staining. RNAseq analysis revealed that MSC from Has-tKO are characterised by decreased expression of genes annotated for bone and organ development, whereas expression of genes associated with chemokine related interactions and cytokine signalling is increased. Taken together, we present a novel mouse model with complete deletion of HA synthases in adult mice which has the potential to study HA function in different organs and during age-related HA reduction. With respect to bone, HA synthesis is important for maintaining bone integrity, presumably based on the strong effect of HA on osteogenic differentiation.

PET/CT for the Opportunistic Screening of Osteoporosis and Fractures in Cancer Patients

PURPOSE OF REVIEW

In this review, we outline the different etiologies of osteoporosis in the oncologic setting and describe the basis for using PET/CT as screening tool for osteoporosis with a focus on the radiotracers [18F]FDG and [18F]NaF.

RECENT FINDINGS

Osteoporosis is a condition commonly affecting cancer patients due to their age, cancer-specific treatment agents, and effects of cancer. In terms of the unifying mechanism, decreased ratio of osteoblast-bone formation to osteoclast-bone resorption is responsible for causing osteoporosis. PET/CT, a crucial metabolic imaging modality in the oncologic imaging, could be a useful tool for the opportunistic screening of osteoporosis. There are two approaches with which osteoporosis could be identified with PET/CT-using either the (1) CT- based or (2) PET- based approaches. While the CT-based approach has been used with [18F]FDG PET/CT, both CT- and PET-based approaches can be employed with [18F]NaF-PET/CT as [18F]NaF is a radiotracer specific for osteoblast activity.

Treatment intensification with radium-223 plus enzalutamide in patients with metastatic castration-resistant prostate cancer

Several life-prolonging therapies with diverse mechanisms of action (MoA) are available for the treatment of metastatic hormone-sensitive/castration-resistant prostate cancer, with many patients requiring multiple lines of therapy. Nevertheless, treatment optimization to further delay disease progression and improve overall survival remains an unmet need. Despite the number of agents with differing MoAs approved for advanced prostate cancer, many patients receive only one or two life-prolonging therapies. One strategy for enhancing the benefit of treatment for this aggressive disease is combining therapies with different MoAs (treatment intensification) early in the disease course, which may be more effective than administering therapies sequentially, yet still allow for subsequent sequential use of individual therapies to optimize patient outcomes. In this narrative review we discuss the rationale for combining 223radium dichloride (223Ra; an alpha-emitting radionuclide) with enzalutamide (an androgen receptor inhibitor) for treatment intensification, including their differing MoAs, their individual efficacy in this setting, and their largely non-overlapping tolerability profiles. We also summarize the preclinical and clinical data available for this combination to date, including interim safety data from the phase 3 EORTC 1333/PEACE III study which highlight the low fracture risk of 223Ra plus enzalutamide when administered concomitantly with bone health agents. Relevant data were sourced from clinical studies published by the authors and via searches of PubMed, clinical trial registries and congress abstracts.

Targeting Calcitriol Metabolism in Acute Vitamin D Toxicity-A Comprehensive Review and Clinical Insight

High-dose vitamin D supplementation is common in the general population, but unsupervised high-dose supplementation in vitamin D-replete individuals poses a risk of severe toxicity. Susceptibility to vitamin D toxicity shows a significant inter-individual variability that may in part be explained by genetic predispositions (i.e., CYP24A1 polymorphism). The classic manifestation of vitamin D toxicity is hypercalcemia, which may be refractory to conventional therapy. Its causes include the endogenous overaction of 1α-hydroxylase, monogenic alterations affecting vitamin D metabolizing enzymes and exogenous vitamin D intoxication. In this manuscript, we include a literature review of potential pharmacological interventions targeting calcitriol metabolism to treat vitamin D intoxication and present a case of severe, exogenous vitamin D intoxication responding to systemic corticosteroids after the failure of conventional therapy. Systemic glucocorticoids alleviate acute hypercalcemia by inhibiting enteric calcium absorption and increasing the degradation of vitamin D metabolites but may cause adverse effects. Inhibitors of 1α-hydroxylase (keto/fluconazole) and inducers of CYP3A4 (rifampicin) may be considered steroid-sparing alternatives for the treatment of vitamin D intoxication.

Prevalence and Factors Associated with Sarcopenia in Post-Menopausal Women with Rheumatoid Arthritis

Objective/Aim

To estimate the prevalence of sarcopenia in post-menopausal women with rheumatoid arthritis (RA) and to investigate possible correlation with disease parameters.

Methods

Eighty post-menopausal women with RA and thirty post-menopausal controls were enrolled in this cross-sectional study. RA patients were further divided in two groups according to the existence of sarcopenia. Sarcopenia was defined according to EWGSOP-II recommendations and osteoporosis as a T-score≤-2.5 in femoral neck bone mineral density. Biomarkers of bone turnover were determined. RA disease activity was calculated using the DAS28-ESR score and inflammatory markers (ESR, CRP). Functionality was calculated with the HAQ-DI score and seropositivity was determined according to RF and anti-CCP antibodies.

Results

Thirty-two post-menopausal women with RA (39%) met the EWGSOP-II criteria for sarcopenia. None of the control subjects was detected with sarcopenia (p<0.0001). All parameters that define sarcopenia were significantly lower in the RA group. Sarcopenic RA patients had significantly lower mean BMI (27.1 kg/m2 vs. 30.5 kg/m2, p=0.008), daily physical activity (IPAQ score) (1213 vs 2867, p<0.0001), mean skeletal muscle mass (ASMI) (5.2 kg/m2 vs 6.6 kg/m2, p<0.0001) and handgrip strength (13.7 kg vs 20.1 kg, p<0.0001). No differences were observed in disease parameters or in biomarkers of bone turnover. IGF-1 was the only parameter that differed between the sarcopenic and non-sarcopenic RA patients (90.1 ng/ml vs 112.8 ng/ml, p=0.024).

Conclusion

Sarcopenia is more common in RA patients. Sarcopenic RA patients had lower BMI, IPAQ, ASMI and handgrip strength. IGF-1 was the only parameter that was significantly lower in sarcopenic RA patients.

Loss of BACH1 improves osteogenic differentiation in glucocorticoid-induced hBMSCs through restoring autophagy

BACKGROUND

Glucocorticoid-induced osteoporosis (GIOP) is the most common type of secondary osteoporosis. Recently, autophagy has been found to be related with the development of various diseases, including osteoporosis and osteoblast differentiation regulations. BTB and CNC homology 1 (BACH1) was a previously confirmed regulator for osteoblast differentiation, but whether it's could involve in glucocorticoid-induced human bone mesenchymal stem cells (hBMSCs) differentiation and autophagy regulation remain not been elucidated.

METHODS

hBMSCs were identified by flow cytometry method, and its differentiation ability were measured by ARS staining, oil O red, and Alcian blue staining assays. Gene and proteins were quantified via qRT-PCR and western blot assays, respectively. Autophagy activity was determined using immunofluorescence. ChIP and dual luciferase assay validated the molecular interactions.

RESULTS

The data revealed that isolated hBMSCs exhibited positive of CD29/CD44 and negative CD45/CD34. Moreover, BACH1 was abated gradually during osteoblast differentiation of hBMSCs, while dexamethasone (Dex) treatment led to BACH1 upregulation. Loss of BACH1 improved osteoblast differentiation and activated autophagy activity in Dex-challenged hBMSCs. Autophagy-related proteins (ATG3, ATG4, ATG5, ATG7, ATG12) were repressed after Dex treatment, while ATG3, ATG7 and BECN1 could be elevated by BACH1 knockdown, especially ATG7. Moreover, BACH1 could interact ATG7 promoter region to inhibit its transcription. Co-inhibition of ATG7 greatly overturned the protective roles of BACH1 loss on osteoblast differentiation and autophagy in Dex-induced hBMSCs.

CONCLUSION

Taken together, our results demonstrated that silencing of BACH1 mitigated Dex-triggered osteogenic differentiation inhibition by transcriptionally activating ATG7-mediated autophagy, suggesting that BACH1 may be a therapeutic target for GIOP treatment.

Lonicera japonica Fermented by Lactobacillus plantarum Improve Multiple Patterns Driven Osteoporosis

Osteoporosis (OP) represents a global health challenge. Certain functional food has the potential to mitigate OP. Honeysuckle (Lonicera japonica) solution has medicinal effects, such as anti-inflammatory and immune enhancement, and can be used in functional foods such as health drinks and functional snacks. The composition of honeysuckle changed significantly after fermentation, and 376 metabolites were enriched. In this study, we used dexamethasone to induce OP in the rat model. Research has confirmed the ability of FS (fermented Lonicera japonica solution) to enhance bone mineral density (BMD), repair bone microarchitectural damage, and increase blood calcium levels. Markers such as tartrate-resistant acid phosphatase-5b (TRACP-5b) and pro-inflammatory cytokines (TNF-α and IL-6) were notably decreased, whereas osteocalcin (OCN) levels increased after FS treatment. FS intervention in OP rats restored the abundance of 6 bacterial genera and the contents of 17 serum metabolites. The results of the Spearman correlation analysis showed that FS may alleviate OP by restoring the abundance of 6 bacterial genera and the contents of 17 serum metabolites, reducing osteoclast differentiation, promoting osteoblast differentiation, and reducing the inflammatory response. This study revealed that Lactobacillus plantarum-fermented honeysuckle alleviated OP through intestinal bacteria and serum metabolites and provided a theoretical basis for the development of related functional foods.

Deficiency of protein C or protein S as a possible cause of osteoporosis

Proteins C and S are vitamin K-dependent anticoagulative factors that also exert a significant influence on bone quality. Clinical studies have linked the deficiency of proteins C and S to lower bone mineral density and the onset of femoral head osteonecrosis in children. Rare foundational studies analyzing this topic have demonstrated that activated protein C, upon binding to the endothelial protein C receptor expressed on the surface of osteoblasts, promotes osteoblast proliferation. It is also established that proteins C and S play crucial roles in proper collagen synthesis and in maintaining the number of osteoclasts and blood vessels. However, the association between protein C and/or S deficiency and the gradual onset of osteoporosis remains largely uninvestigated. Calculations based on data from peer-reviewed journals suggest that approximately one in every 10 individuals may develop osteoporosis due to congenital protein C or S deficiency. Moreover, when secondary causes of protein C and S deficiency are also considered, the proportion likely further increases. In this paper, we discuss the pathophysiological background of the potential relationship between protein C and S deficiency and the genesis of osteoporosis.

Higher cumulative dose of topical corticosteroids is associated with osteoporosis and major osteoporotic fracture: A nationwide case-control study

BACKGROUND

Connections between long-term use of topical corticosteroids (TCSs) of varying potency and osteoporosis and major osteoporotic fracture (MOF) are unclear. Susceptibility to adverse bone effects of TCSs in different sex, age and ethnic groups is unknown too.

OBJECTIVES

To demonstrate the association between cumulative dose of TCSs of varying potency and osteoporosis and MOF in Taiwanese population, with stratified analysis of sex and age.

METHODS

We conducted a nationwide case-control study and obtained data from Taiwan National Health Insurance Research Database. Cumulative TCS doses in different exposure periods were calculated, and the potency of TCSs was converted to prednisolone equivalent. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for osteoporosis and MOF associated with TCS use.

RESULTS

From 2017 to 2020, 129,682 osteoporosis cases and 34,999 MOF cases were selected and randomly matched with 518,728 and 139,996 controls by sex and age. We found clear dose-response relationships between long-term TCS exposure and osteoporosis and MOF. For example, compared to no TCS use, adjusted ORs of osteoporosis were 1.216 (95% CI 1.189-1.243), 1.260 (95% CI, 1.241-1.280) and 1.341 (95% CI, 1.314-1.369) for exposure to low, medium and high cumulative TCS doses, respectively, over 5 years. Adjusted ORs of MOF were 1.118 (95% CI 1.069-1.170), 1.191 (95% CI, 1.156-1.227) and 1.288 (95% CI, 1.238-1.340) for exposure to low, medium and high cumulative TCS doses, respectively, over 5 years. Stratified analysis showed women had higher ORs of osteoporosis and MOF compared to men. Younger people (<50 years) had highest OR of osteoporosis compared to other age groups.

CONCLUSIONS

Higher cumulative TCS dose was associated with increased risk of osteoporosis and MOF. Long-term use of TCSs should be cautious, especially in susceptible populations such as women and young people.

Mitochondria from osteolineage cells regulate myeloid cell-mediated bone resorption

Interactions between osteolineage cells and myeloid cells play important roles in maintaining skeletal homeostasis. Herein, we find that osteolineage cells transfer mitochondria to myeloid cells. Impairment of the transfer of mitochondria by deleting MIRO1 in osteolineage cells leads to increased myeloid cell commitment toward osteoclastic lineage cells and promotes bone resorption. In detail, impaired mitochondrial transfer from osteolineage cells alters glutathione metabolism and protects osteoclastic lineage cells from ferroptosis, thus promoting osteoclast activities. Furthermore, mitochondrial transfer from osteolineage cells to myeloid cells is involved in the regulation of glucocorticoid-induced osteoporosis, and glutathione depletion alleviates the progression of glucocorticoid-induced osteoporosis. These findings reveal an unappreciated mechanism underlying the interaction between osteolineage cells and myeloid cells to regulate skeletal metabolic homeostasis and provide insights into glucocorticoid-induced osteoporosis progression.

Maternal prednisone exposure during pregnancy elevates susceptibility to osteoporosis in female offspring: The role of mitophagy/FNDC5 alteration in skeletal muscle

Maternal exposure to glucocorticoids has been associated with adverse outcomes in offspring. However, the consequences and mechanisms of gestational exposure to prednisone on susceptibility to osteoporosis in the offspring remain unclear. Here, we found that gestational prednisone exposure enhanced susceptibility to osteoporosis in adult mouse offspring. In a further exploration of myogenic mechanisms, results showed that gestational prednisone exposure down-regulated FNDC5/irisin protein expression and activation of OPTN-dependent mitophagy in skeletal muscle of adult offspring. Additional experiments elucidated that activated mitophagy significantly inhibited the expression of FNDC5/irisin in skeletal muscle cells. Likewise, we observed delayed fetal bone development, downregulated FNDC5/irisin expression, and activated mitophagy in fetal skeletal muscle upon gestational prednisone exposure. In addition, an elevated total m6A level was observed in fetal skeletal muscle after gestational prednisone exposure. Finally, gestational supplementation with S-adenosylhomocysteine (SAH), an inhibitor of m6A activity, attenuated mitophagy and restored FNDC5/irisin expression in fetal skeletal muscle, which in turn reversed fetal bone development. Overall, these data indicate that gestational prednisone exposure increases m6A modification, activates mitophagy, and decreases FNDC5/irisin expression in skeletal muscle, thus elevating osteoporosis susceptibility in adult offspring. Our results provide a new perspective on the earlier prevention and treatment of fetal-derived osteoporosis.

The association between body mass index and osteoporosis in a Taiwanese population: a cross-sectional and longitudinal study

This study investigates the correlation between body mass index (BMI) and osteoporosis utilizing data from the Taiwan Biobank. Initially, a comprehensive analysis of 119,009 participants enrolled from 2008 to 2019 was conducted to assess the association between BMI and osteoporosis prevalence. Subsequently, a longitudinal cohort of 24,507 participants, initially free from osteoporosis, underwent regular follow-ups every 2-4 years to analyze the risk of osteoporosis development, which was a subset of the main cohort. Participants were categorized into four BMI groups: underweight (BMI < 18.5 kg/m2), normal weight (18.5 kg/m2 ≤ BMI < 24 kg/m2), overweight (24 kg/m2 ≤ BMI < 27 kg/m2), and obese groups (BMI ≥ 27 kg/m2). A T-score ≤ - 2.5 standard deviations below that of a young adult was defined as osteoporosis. Overall, 556 (14.1%), 5332 (9.1%), 2600 (8.1%) and 1620 (6.7%) of the participants in the underweight, normal weight, overweight and obese groups, respectively, had osteoporosis. A higher prevalence of osteoporosis was noted in the underweight group compared with the normal weight group (odds ratio [OR], 2.20; 95% confidence interval [95% CI], 1.99 to 2.43; p value < 0.001) in multivariable binary logistic regression analysis. Furthermore, in the longitudinal cohort during a mean follow-up of 47 months, incident osteoporosis was found in 61 (9%), 881 (7.2%), 401 (5.8%) and 213 (4.6%) participants in the underweight, normal weight, overweight and obese groups, respectively. Multivariable Cox proportional hazards analysis revealed that the risk of incident osteoporosis was higher in the underweight group than in the normal weight group (hazard ratio [HR], 1.63; 95% CI 1.26 to 2.12; p value < 0.001). Our results suggest that BMI is associated with both the prevalence and the incidence of osteoporosis. In addition, underweight is an independent risk factor for developing osteoporosis. These findings highlight the importance of maintaining normal weight for optimal bone health.

Risk of fractures and use of bisphosphonates in adult patients with immune thrombocytopenia-A nationwide population-based study

Corticosteroids remain the first-line treatment of immune thrombocytopenia (ITP), but increase the risk of osteoporosis and fractures. Bisphosphonates are used for the treatment of osteoporosis, but their usage among patients with ITP has not been systemically described. We investigated the risk of fractures and the use of bisphosphonates in adult patients with primary (pITP) and secondary ITP (sITP) compared with matched comparators in a nationwide registry-based cohort study. We identified 4030 patients with pITP (median age 60 years [IQR, 40-74]), 550 with sITP (median age 59 years [IQR, 43-74]) and 182 939 age-sex-matched general population comparators. All individuals were followed for incident fractures. Bisphosphonate use was estimated for calendar-years and in temporal relation to the ITP diagnosis. Adjusted cause-specific hazard ratio (csHR) for any fracture was 1.37 (95% confidence interval [CI] 1.23; 1.54) for pITP and 1.54 (1.17; 2.03) for sITP. The first-year csHR was 1.82 (1.39; 2.40) for pITP and 2.78 (1.58; 4.91) for sITP. Bisphosphonate use over calendar-years and in the early years following ITP diagnosis was higher among patients with ITP diagnosis compared with the general population. In conclusion, the risk of fractures and the use of bisphosphonates are higher in patients with ITP compared with the general population.

A review of hyaluronic acid-based therapeutics for the treatment and management of arthritis

Hyaluronic acid (HA), a biodegradable, biocompatible and non-immunogenic therapeutic polymer is a key component of the cartilage extracellular matrix (ECM) and has been widely used to manage two major types of arthritis, osteoarthritis (OA) and rheumatoid arthritis (RA). OA joints are characterized by lower concentrations of depolymerized (low molecular weight) HA, resulting in reduced physiological viscoelasticity, while in RA, the associated immune cells are over-expressed with various cell surface receptors such as CD44. Due to HA's inherent viscoelastic property and its ability to target CD44, there has been a surge of interest in developing HA-based systems to deliver various bioactives (drugs and biologics) and manage arthritis. Considering therapeutic benefits of HA in arthritis management and potential advantages of novel delivery systems, bioactive delivery through HA-based systems is beginning to display improved outcomes over bioactive only treatment. The benefits include enhanced bioactive uptake due to receptor-mediated targeting, prolonged retention of bioactives in the synovium, reduced expressions of proinflammatory mediators, enhanced cartilage regeneration, reduced drug toxicity due to sustained release, and improved and cost-effective treatment. This review provides an underlying rationale to prepare and use HA-based bioactive delivery systems for arthritis applications. With special emphasis given to preclinical/clinical results, this article reviews various bioactive-loaded HA-based particulate carriers (organic and inorganic), gels, scaffolds and polymer-drug conjugates that have been reported to treat and manage OA and RA. Furthermore, the review identifies several key challenges and provides valuable suggestions to address them. Various developments, strategies and suggestions described in this review may guide the formulation scientists to optimize HA-based bioactive delivery systems as an effective approach to manage and treat arthritis effectively.

Korean red ginseng extract prevents bone loss in an oral model of glucocorticoid induced osteoporosis in mice

The gut microbiota and barrier function play important roles in bone health. We previously demonstrated that chronic glucocorticoid (GC)-induced bone loss in mice is associated with significant shifts in gut microbiota composition and impaired gut barrier function. Korean Red Ginseng (KRG, Panax Ginseng Meyer, Araliaceae) extract has been shown to prevent glucocorticoid-induced osteoporosis (GIO) in a subcutaneous pellet model in mice, but its effect on gut microbiota and barrier function in this context is not known. The overall goal of this study was to test the effect of KRG extract in a clinically relevant, oral model of GIO and further investigate its role in modulating the gut-bone axis. Growing male mice (CD-1, 8 weeks) were treated with 75 μg/mL corticosterone (∼9 mg/kg/day) or 0.4% ethanol vehicle in the drinking water for 4 weeks. During this 4-week period, mice were treated daily with 500 mg/kg/day KRG extract dissolved in sterile water or an equal amount of sterile water via oral gastric gavage. After 4 weeks of treatment, we assessed bone volume, microbiota composition, gut barrier integrity, and immune cells in the bone marrow (BM) and mesenteric lymph nodes (MLNs). 4 weeks of oral GC treatment caused significant distal femur trabecular bone loss, and this was associated with changes in gut microbiota composition, impaired gut barrier function and altered immune cell composition. Importantly, KRG extract prevented distal femur trabecular bone loss and caused significant alterations in gut microbiota composition but had only modest effects on gut barrier function and immune cell populations. Taken together, these results demonstrate that KRG extract significantly modulates the gut microbiota-bone axis and prevents glucocorticoid-induced bone loss in mice.

A view on the skin-bone axis: unraveling similarities and potential of crosstalk

The phrase "skin as a mirror of internal medicine," which means that the skin reflects many of the diseases of the internal organs, is a well-known notion. Despite the phenotypic differences between the soft skin and hard bone, the skin and bone are highly associated. Skin and bone consist of fibroblasts and osteoblasts, respectively, which secrete collagen and are involved in synthesis, while Langerhans cells and osteoclasts control turnover. Moreover, the quality and quantity of collagen in the skin and bone may be modified by aging, inflammation, estrogen, diabetes, and glucocorticoids. Skin and bone collagen are pathologically modified by aging, drugs, and metabolic diseases, such as diabetes. The structural similarities between the skin and bone and the crosstalk controlling their mutual pathological effects have led to the advocacy of the skin-bone axis. Thus, the skin may mirror the health of the bones and conversely, the condition of the skin may be reflected in the bones. From the perspective of the skin-bone axis, the similarities between skin and bone anatomy, function, and pathology, as well as the crosstalk between the two, are discussed in this review. A thorough elucidation of the pathways governing the skin-bone axis crosstalk would enhance our understanding of disease pathophysiology, facilitating the development of new diagnostics and therapies for skin collagen-induced bone disease and of new osteoporosis diagnostics and therapies that enhance skin collagen to increase bone quality and density.

Exposure to perfluoroalkyl substances and longitudinal changes in bone mineral density in adolescents and young adults: A multi-cohort study

BACKGROUND

Per- and polyfluoroalkyl substances (PFAS) may impair bone development in adolescence, which impacts life-long bone health. No previous studies have examined prospective associations of individual PFAS and their mixture with bone mineral density (BMD) changes in Hispanic young persons, a population at high risk of osteoporosis in adulthood.

OBJECTIVES

To examine associations of individual PFAS and PFAS mixtures with longitudinal changes in BMD in an adolescent Hispanic cohort and examine generalizability of findings in a mixed-ethnicity young adult cohort (58.4% Hispanic).

METHODS

Overweight/obese adolescents from the Study of Latino Adolescents at Risk of Type 2 Diabetes (SOLAR; n = 304; mean follow-up = 1.4 years) and young adults from the Southern California Children's Health Study (CHS; n = 137; mean follow-up = 4.1 years) were included in this study. Plasma PFAS were measured at baseline and dual x-ray absorptiometry scans were performed at baseline and follow-up to measure BMD. We estimated longitudinal associations between BMD and five PFAS via separate covariate-adjusted linear mixed effects models, and between BMD and the PFAS mixture via quantile g-computation.

RESULTS

In SOLAR adolescents, baseline plasma perfluorooctanesulfonic acid (PFOS) was associated with longitudinal changes in BMD. Each doubling of PFOS was associated with an average -0.003 g/cm2 difference in change in trunk BMD per year over follow-up (95% CI: -0.005, -0.0002). Associations with PFOS persisted in CHS young adults, where each doubling of plasma PFOS was associated with an average -0.032 g/cm2 difference in total BMD at baseline (95% CI -0.062, -0.003), though longitudinal associations were non-significant. We did not find associations of other PFAS with BMD; associations of the PFAS mixture with BMD outcomes were primarily negative though non-significant.

DISCUSSION

PFOS exposure was associated with lower BMD in adolescence and young adulthood, important periods for bone development, which may have implications on future bone health and risk of osteoporosis in adulthood.

Insights and implications of sexual dimorphism in osteoporosis

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

Agomelatine alleviates steroid-induced osteoporosis by targeting SIRT1/RANKL/FOXO1/OPG signalling in rats

One of the major contributors to secondary osteoporosis is long-term glucocorticoid usage. Clinically used antidepressant agomelatine also has anti-inflammatory properties. Our research aimed to inspect the probable defensive effect of agomelatine against steroid-promoted osteoporosis. There were four groups of rats; group I had saline as a negative control; rats of group II had dexamethasone (0.6 mg/kg, s.c.), twice weekly for 12 weeks; rats of group III had agomelatine (40 mg/kg/day, orally), as a positive control, daily for 12 weeks; and rats of group IV had dexamethasone + agomelatine in the same previous doses combined for 12 weeks. Finally, biochemical as well as histopathological changes were evaluated and dexamethasone treatment caused osteoporosis, as evidenced by discontinuous thin cancellous bone trabeculae, minor fissures and fractures, irregular eroded endosteal surface with elevated alkaline phosphate, tartarate resistant acid phosphate (TRACP) and osteocalcin levels. Osteoprotegerin (OPG), calcium, and phosphorus levels decreased with disturbed receptor activator of nuclear factor κ B ligand (RANKL), forkhead box O1 (FOXO1), and silent information regulator 1 (SIRT1) protein expression. However, treatment with agomelatine restored the normal levels of biochemical parameters to a great extent, supported by SIRT activation with an improvement in histopathological changes. Here, we concluded that agomelatine ameliorates steroid-induced osteoporosis through a SIRT1/RANKL/FOXO1/OPG-dependent pathway.

Ionized hypercalcemia can resolve with nutritional modification in cats with idiopathic hypercalcemia or chronic kidney disease

CASE SERIES SUMMARY

Cats with ionized hypercalcemia that were fed diets with either more than 200 mg calcium per 100 kilocalories (kcal), a calcium:phosphorus (Ca:P) ratio greater than 1.4:1 or both, based on diet history, were included in this case series. Ionized hypercalcemia was documented at least twice in all cats before enrollment. Cats were referred for evaluation of ionized hypercalcemia (n = 5) or were incidentally found to have ionized hypercalcemia (n = 5). After medical workups, cats were diagnosed with either idiopathic hypercalcemia (IHC; n = 7) or chronic kidney disease (n = 3). Cats receiving medications to treat IHC (eg, alendronate, corticosteroids) were excluded. Nutritional recommendations were made to transition the cats to diets with less thn 200 mg calcium per 100 kcal and a Ca:P ratio less than 1.4:1. Ionized calcium (iCa) concentrations were rechecked in all cats, with a median recheck time of 9 weeks (range 3-20). Of the 10 cats, nine (90%) had a decrease in iCa. Of the 10 cats, six (60%) became normocalcemic after the diet change, three (30%) had a partial response and one (10%) did not respond. Of the four cats that did not achieve normocalcemia with a change in diet, two (50%) received chia seeds (1-2 g per day), and at the next recheck, both cats' iCa concentrations had normalized. Three cats had a long-term follow-up. Ionized normocalcemia was maintained for at least two consecutive follow-up visits over a median follow-up period of 33 weeks (range 12-34).

RELEVANCE AND NOVEL INFORMATION

Dietary calcium concentrations and the dietary Ca:P ratio appear to be important variables in considering nutritional approaches for hypercalcemic cats.

Multimorbidity in Rheumatoid Arthritis: Literature Review and Future Directions

PURPOSE OF REVIEW

To offer a narrative review of literature and an update on rheumatoid arthritis (RA) multimorbidity research over the past five years as well as future directions.

RECENT FINDINGS

Patients with RA experience higher prevalence of multimorbidity (31-86% vs 18-71% in non-RA) and faster accumulation of comorbidities. Patients with multimorbidity have worse outcomes compared to non-RA multimorbid patients and RA without multimorbidity including mortality, cardiac events, and hospitalizations. Comorbid disease clusters often included: cardiopulmonary, cardiometabolic, and depression and pain-related conditions. High-frequency comorbidities included interstitial lung disease, asthma, chronic obstructive pulmonary disease, cardiovascular disease, fibromyalgia, osteoarthritis, and osteoporosis, thyroid disorders, hypertension, and cancer. Furthermore, patients with RA and multimorbidity are paradoxically at increased risk of high RA disease activity but experience a lower likelihood of biologic use and more biologic failures. RA patients experience higher prevalence of multimorbidity and worse outcomes versus non-RA and RA without multimorbidity. Findings call for further studies.

Chronic obstructive pulmonary disease is an independent risk factor for increased opioid use in total hip arthroplasty: A retrospective PearlDiver study

Background

Total hip arthroplasty (THA) has become an incredibly common procedure due to its' predictability and high success rate. The success of surgery is related to strict indications and careful optimization of medical comorbidities to decrease risk and improve outcomes. Chronic obstructive pulmonary disease (COPD) has been associated with increased medical and surgical complications. A regulatory focus on opioid utilization does not usually consider COPD as a risk factor, but limited research exists on the impact of COPD on outcomes and risks after THA.

Methods

Retrospective all-inclusive database analysis of Medicare patients who had undergone THA between 2007 and 2017 included in the PearlDiver Database were studied. Postoperative opioid usage was examined at 1-, 3-, 6-, and 12 months, along with surgical infection, implant complications, and revisions. Post-operative complications within 30 days, either medical or implant related, were identified. Controlling for comorbidities, age, and sex, odds ratios were calculated using multivariable logistic regression with a significant α value of 0.05.

Results

COPD patients had significantly higher rates of opioid usage postoperatively. COPD patients also had an increased rate of readmissions, medical/implant complications, and revision surgeries.

Discussion

This is the only study raising concern regarding opioid use in COPD patients after total hip arthroplasty, which may be critical considering the associated respiratory depression further exacerbating the COPD. Considering the evidence of poor outcomes associated with COPD in arthroplasty, appropriately screening for COPD and counseling or planning for post-operative pain control and complications is paramount.

Effect of long-term medium to high-dose inhaled budesonide on bone mineral density in children with asthma: a cross-sectional study

OBJECTIVE

The objective of this study was to examine the impact of long-term medium to high-dose inhaled budesonide on bone mineral density in children with asthma.

METHODS

We conducted a cross-sectional study in children aged 7-17 years with asthma, who received long-term (≥2 years), medium to high-dose inhaled budesonide (≥400μg/day in 6-11 years old; ≥800 μg/day in >11 years old). We measured bone mineral density (BMD) using dual-energy X-ray absorptiometry and compared it with reference Indian normative values.

RESULTS

Thirty-five children with moderate to severe asthma receiving long-term medium to high-dose inhaled budesonide, were included in the study. We found a significantly low lumbar-spine BMD in the study population compared to reference Indian values (p-value 0.002). Eight cases had short stature. Despite the adjustment for height-age in these short-stature cases, lumbar-spine BMD remained significantly low in the study population (p-value 0.020). No significant difference was found in 25-hydroxy vitamin D levels between subjects with "low BMD" and "BMD z-score > -2".

CONCLUSIONS

The findings of this study suggest that long-term medium to high-dose inhaled budesonide treatment in children with asthma is associated with decreased BMD. However, further investigation with a larger sample size is necessary to confirm this relationship.

Musculoskeletal and Psychological Rehabilitation

Background

Although it has long been believed that stress has a detrimental effect on health and the risk of disease, little research has been done on the precise mechanisms by which this happens. The literature produced by past workers suggests many possibly intersecting mechanistic pathways that might be useful for future fundamental and clinical study. Exercise has been thoroughly researched as a non-pharmacologic strategy to increase bone mass. Many evidence-based treatment recommendations for patients suffering from osteoporosis-related fractures, potential courses of care, and rehabilitation concur that multidisciplinary therapy would be the most beneficial.

Materials and Methods

Older and recent articles about musculoskeletal and psychological rehabilitation in the management of osteoporosis published in prominent and reputed journals are reviewed. Important and interesting information from some of the cross-references is also included. Opinions and impressions from the experience of treating osteoporosis are added while describing various aspects of psychological and physical rehabilitation.

Results

The recent evidence, reviewed here, also indicates the possibility of cross-effects between osteoporosis and psychological issues. A multi-factorial and personalised strategy should be explored for improved outcomes in patients under psychological stress, particularly those at increased risk of osteoporosis development. Reviewing current publications, the objectives of rehabilitation are evolving based on the disease's stage. For example, during the initial stage of a vertebral body collapse, the patient is treated with bracing, physical therapy, education, local and systemic analgesics, and a brief period of bed rest. The need to mobilise the patient carefully and safely along with a mix of medical care, dietary supplements, rehabilitation, and instructions to facilitate daily living activities, are endorsed to manage post-fracture osteoporosis.

Conclusion

This chapter is not to make treatment advice, but rather to outline potential connections between psychological stress and low bone density and to emphasise potential multi-system consequences of pharmaceutical therapies. The goal is to enhance activities of daily living, which will increase safety, minimise falls, and maintain bone mass. Osteoporosis and fragility fractures can be prevented and managed with regular medical check-ups, daily exercise and yoga, a healthy diet, fall prevention measures, recreational group activities, supportive medications, control of comorbidities, use of assistive devices, and customised rehabilitation programmes.

Racial/Ethnic Differences in Bone Mineral Density for Osteoporosis

PURPOSE OF REVIEW

We primarily aim to review differences in bone mineral density (BMD) for osteoporosis among different racial/ethnic groups and to highlight the magnitude of racial/ethnic differences in obesity and diabetes. We also explore the factors contributing to the BMD differences among various subgroups. In addition, we investigate the existing disparities in research, educational initiatives, screening practices, and treatment options for osteoporosis and discuss these findings' clinical and public health implications.

RECENT FINDINGS

Racial/ethnic differences in BMD for osteoporosis exist in the USA and other countries. There are disparities regarding osteoporosis screening and treatment. Understanding the factors contributing to these differences can help develop targeted interventions and policies to reduce their impact. Clinicians should consider the racial/ethnic differences in BMD when making treatment decisions and providing preventive care. Future research could contribute to developing effective strategies for preventing osteoporosis among different racial/ethnic groups. This review offered a comprehensive examination of differences in BMD across various racial and ethnic groups, elucidating the influence of genetic, lifestyle, and cultural factors on these differences. This review also highlighted the disparities in osteoporosis screening, treatment options, research on medical effectiveness, and educational outreach tailored to each subgroup. Recognizing the importance of addressing these inequalities, we present this review to advocate for targeted interventions to reduce disparities in osteoporosis and improve bone health for all populations.

An Update on Drug-Nutrient Interactions and Dental Decay in Older Adults

In recent decades, the global demographic landscape has undergone a discernible shift that has been characterised by a progressive increase in the proportion of elderly individuals, indicative of an enduring global inclination toward extended lifespans. The aging process, accompanied by physiological changes and dietary patterns, contributes to detrimental deviations in micronutrient consumption. This vulnerable aging population faces heightened risks, including dental caries, due to structural and functional modifications resulting from insufficient nutritional sustenance. Factors such as physiological changes, inadequate nutrition, and the prevalence of multiple chronic pathologies leading to polypharmacy contribute to the challenge of maintaining an optimal nutritional status. This scenario increases the likelihood of drug interactions, both between medications and with nutrients and the microbiome, triggering complications such as dental decay and other pathologies. Since the drug industry is evolving and new types of food, supplements, and nutrients are being designed, there is a need for further research on the mechanisms by which drugs interfere with certain nutrients that affect homeostasis, exemplified by the prevalence of caries in the mouths of older adults. Infectious diseases, among them dental caries, exert serious impacts on the health and overall quality of life of the elderly demographic. This comprehensive review endeavours to elucidate the intricate interplay among drugs, nutrients, the microbiome, and the oral cavity environment, with the overarching objective of mitigating the potential hazards posed to both the general health and dental well-being of older adults. By scrutinising and optimising these multifaceted interactions, this examination aims to proactively minimise the susceptibility of the elderly population to a spectrum of health-related issues and the consequences associated with dental decay.

Treating the Side Effects of Exogenous Glucocorticoids; Can We Separate the Good From the Bad?

It is estimated that 2% to 3% of the population are currently prescribed systemic or topical glucocorticoid treatment. The potent anti-inflammatory action of glucocorticoids to deliver therapeutic benefit is not in doubt. However, the side effects associated with their use, including central weight gain, hypertension, insulin resistance, type 2 diabetes (T2D), and osteoporosis, often collectively termed iatrogenic Cushing's syndrome, are associated with a significant health and economic burden. The precise cellular mechanisms underpinning the differential action of glucocorticoids to drive the desirable and undesirable effects are still not completely understood. Faced with the unmet clinical need to limit glucocorticoid-induced adverse effects alongside ensuring the preservation of anti-inflammatory actions, several strategies have been pursued. The coprescription of existing licensed drugs to treat incident adverse effects can be effective, but data examining the prevention of adverse effects are limited. Novel selective glucocorticoid receptor agonists and selective glucocorticoid receptor modulators have been designed that aim to specifically and selectively activate anti-inflammatory responses based upon their interaction with the glucocorticoid receptor. Several of these compounds are currently in clinical trials to evaluate their efficacy. More recently, strategies exploiting tissue-specific glucocorticoid metabolism through the isoforms of 11β-hydroxysteroid dehydrogenase has shown early potential, although data from clinical trials are limited. The aim of any treatment is to maximize benefit while minimizing risk, and within this review we define the adverse effect profile associated with glucocorticoid use and evaluate current and developing strategies that aim to limit side effects but preserve desirable therapeutic efficacy.

Disturbed bone marrow adiposity in patients with Cushing's syndrome and glucocorticoid- and postmenopausal- induced osteoporosis

Background

Skeletal stem/progenitor cells (SSPCs) in the bone marrow can differentiate into osteoblasts or adipocytes in response to microenvironmental signalling input, including hormonal signalling. Glucocorticoids (GC) are corticosteroid hormones that promote adipogenic differentiation and are endogenously increased in patients with Cushing´s syndrome (CS). Here, we investigate bone marrow adiposity changes in response to endogenous or exogenous GC increases. For that, we characterize bone biopsies from patients with CS and post-menopausal women with glucocorticoid-induced osteoporosis (GC-O), compared to age-matched controls, including postmenopausal osteoporotic patients (PM-O).

Methods

Transiliac crest bone biopsies from CS patients and healthy controls, and from postmenopausal women with GC-O and matched controls were analysed; an additional cohort included biopsies from women with PM-O. Plastic-embedded biopsies were sectioned for histomorphometric characterization and quantification of adipocytes. The fraction of adipocyte area per tissue (Ad.Ar/T.Ar) and marrow area (Ad.Ar/Ma.Ar), mean adipocyte profile area (Ad.Pf.Ar) and adipocyte profile density (N.Ad.Pf/Ma.Ar) were determined and correlated to steroid levels. Furthermore, the spatial distribution of adipocytes in relation to trabecular bone was characterized and correlations between bone marrow adiposity and bone remodeling parameters investigated.

Results

Biopsies from patients with CS and GC-O presented increased Ad.Ar/Ma.Ar, along with adipocyte hypertrophy and hyperplasia. In patients with CS, both Ad.Ar/Ma.Ar and Ad.Pf.Ar significantly correlated with serum cortisol levels. Spatial distribution analyses revealed that, in CS, the increase in Ad.Ar/Ma.Ar near to trabecular bone (<100 µm) was mediated by both adipocyte hypertrophy and hyperplasia, while N.Ad.Pf/Ma.Ar further into the marrow (>100 µm) remained unchanged. In contrast, patients with GC-O only presented increased Ad.Ar/Ma.Ar and mean Ad.Pf.Ar>100 µm from trabecular bone surface, highlighting the differential effect of increased endogenous steroid accumulation. Finally, the Ad.Ar/Ma.Ar and Ad.Ar/T.Ar correlated with the canopy coverage above remodeling events.

Conclusion

Increased cortisol production in patients with CS induces increased bone marrow adiposity, primarily mediated by adipocyte hypertrophy. This adiposity is particularly evident near trabecular bone surfaces, where hyperplasia also occurs. The differential pattern of adiposity in patients with CS and GC-O highlights that bone marrow adipocytes and their progenitors may respond differently in these two GC-mediated bone diseases.

Advancing our understanding of the influence of drug induced changes in the gut microbiome on bone health

The gut microbiome has been implicated in a multitude of human diseases, with emerging evidence linking its microbial diversity to osteoporosis. This review article will explore the molecular mechanisms underlying perturbations in the gut microbiome and their influence on osteoporosis incidence in individuals with chronic diseases. The relationship between gut microbiome diversity and bone density is primarily mediated by microbiome-derived metabolites and signaling molecules. Perturbations in the gut microbiome, induced by chronic diseases can alter bacterial diversity and metabolic profiles, leading to changes in gut permeability and systemic release of metabolites. This cascade of events impacts bone mineralization and consequently bone mineral density through immune cell activation. In addition, we will discuss how orally administered medications, including antimicrobial and non-antimicrobial drugs, can exacerbate or, in some cases, treat osteoporosis. Specifically, we will review the mechanisms by which non-antimicrobial drugs disrupt the gut microbiome's diversity, physiology, and signaling, and how these events influence bone density and osteoporosis incidence. This review aims to provide a comprehensive understanding of the complex interplay between orally administered drugs, the gut microbiome, and osteoporosis, offering new insights into potential therapeutic strategies for preserving bone health.

Adverse Outcomes, Healthcare Resource Utilization, and Costs Associated with Systemic Corticosteroid use Among Adults with Systemic Lupus Erythematosus in the UK

INTRODUCTION

This analysis was conducted to assess the incidence of adverse clinical outcomes, healthcare resource use (HCRU), and the costs associated with systemic corticosteroid (SCS) use in adults with systemic lupus erythematosus (SLE) in the UK.

METHODS

We identified incident SLE cases using the Clinical Practice Research Datalink GOLD, Hospital Episode Statistics-linked healthcare, and Office for National Statistics mortality databases from January 1, 2005, to June 30, 2019. Adverse clinical outcomes, HCRU, and costs were captured for patients with and without prescribed SCS.

RESULTS

Of 715 patients, 301 (42%) had initiated SCS use (mean [standard deviation (SD)] 3.2 [6.0] mg/day) and 414 (58%) had no recorded SCS use post-SLE diagnosis. Cumulative incidence of any adverse clinical outcome over 10-year follow-up was 50% (SCS group) and 22% (non-SCS group), with osteoporosis diagnosis/fracture most frequently reported. SCS exposure in the past 90 days was associated with an adjusted hazard ratio of 2.41 (95% confidence interval 1.77-3.26) for any adverse clinical outcome, with increased hazard for osteoporosis diagnosis/fracture (5.26, 3.61-7.65) and myocardial infarction (4.52, 1.16-17.71). Compared to low-dose SCS (< 7.5 mg/day), patients on high-dose SCS (≥ 7.5 mg/day) had increased hazard for myocardial infarction (14.93, 2.71-82.31), heart failure (9.32, 2.45-35.43), osteoporosis diagnosis/fracture (5.14, 2.82-9.37), and type 2 diabetes (4.02 1.13-14.27). Each additional year of SCS use was associated with increased hazard for any adverse clinical outcome (1.15, 1.05-1.27). HCRU and costs were greater for SCS users than non-SCS users.

CONCLUSIONS

Among patients with SLE, there is a higher burden of adverse clinical outcomes and greater HCRU in SCS versus non-SCS users.

Construction of predictive model for osteoporosis related factors among postmenopausal women on the basis of logistic regression and Bayesian network

Osteoporosis is a prevalent chronic disease that often goes unnoticed in postmenopausal women. Early identification of risk factors for osteoporosis in postmenopausal women is essential. This study aimed to develop predictive models for osteoporosis-related factors among postmenopausal women in the U.S. and explore the influencing factors. In this cross-sectional study, we included 4417 postmenopausal women from the NHANES (2009-2010, 2013-2014, and 2017-2020). Through multiple regression analysis, we found that age, minutes of sedentary activity, prednisone or cortisone usage, arthritis, bone loss around teeth, and trouble sleeping were risk factors for osteoporosis after menopause. Conversely, height, BMI, and age at the last menstrual period were identified as protective factors. The findings from the Bayesian network analysis indicated that several factors influenced osteoporosis, including age, BMI, bone loss around teeth, prednisone or cortisone usage, arthritis, and age at the last menstrual period. On the other hand, minutes of sedentary activity and height might have indirect effects, while trouble sleeping may not have a significant impact. Both logistic regression and Bayesian network models demonstrated good predictive capabilities in predicting osteoporosis among postmenopausal women. In addition, Bayesian networks offer a more intuitive depiction of the intricate network risk mechanism between diseases and factors.

Osteoporosis as the First Sign of Cushing's Disease in a Thin 16-Year-Old Boy-A Case Report

Cushing's disease (CD) is an extremely rare diagnosis in children. In this report, we present the case of an almost 16-year-old, short and thin boy with CD, the first symptoms of which were spinal pain and vertebral fractures as a result of osteoporosis. In light of his growth retardation and short stature, the boy underwent diagnostics, which excluded growth hormone (GH) deficiency, hypothyroidism and celiac disease. Finally, based on cortisol profile results, dexamethasone suppression tests and bilateral sampling during catheterization of the inferior petrosal sinuses, CD was diagnosed.

Ca-DEX biomineralization-inducing nuts reverse oxidative stress and bone loss in rheumatoid arthritis

Rheumatoid arthritis (RA) is a common autoimmune disease, and the inflammatory response during its development can lead to joint cartilage and bone damage up to disability. Dexamethasone (DEX) can effectively alleviate the inflammatory response in RA, but the severe adverse effects that occur after its long-term administration limit its clinical development. Herein, we propose a Ca-DEX biomineralization-inducing nut (CaCO3-DEX) with controlled release properties for mitigating the toxic side effects of DEX in RA treatment, especially the damage to cartilage and bone. CaCO3-DEX releases the drug and Ca2+ preferentially in an inflammatory environment. Both in vitro and in vivo studies demonstrate that CaCO3-DEX significantly reduces the secretion of pro-inflammatory factors and inhibits ROS production in vitro, as well as demonstrates superior pro-biomineralization and osteogenic differentiation potential. In the collagen-induced rheumatoid arthritis model (CIA model), CaCO3-DEX significantly reduces the clinical score of arthritis in mice, and the imaging results show a noticeable relief of edema and bone erosion in CIA model mice treated with CaCO3-DEX, while inflammatory factors at the injury areas are significantly reduced, which provides favorable protection to cartilage and bone.

Enzalutamide Prior to Radium-223 Is Associated with Better Overall Survival in Metastatic Castration-Resistant Prostate Cancer Patients Compared to Abiraterone-A Retrospective Study

Metastatic castration-resistant prostate cancer (mCRPC) is a progressive stage of prostate cancer that often spreads to the bone. Radium-223, a bone-targeting radiopharmaceutical, has been shown to improve the overall survival in mCRPC in patients without visceral metastasis. However, the impact of prior systemic therapy on the treatment outcome of mCRPC patients receiving radium-223 remains unclear. This study aimed to investigate the optimal choice of systemic therapy before radium-223 in mCRPC patients. The study included 41 mCRPC patients who received radium-223 therapy, with 22 receiving prior enzalutamide and 19 receiving prior abiraterone. The results showed that the median overall survival was significantly longer in the enzalutamide group than in the abiraterone group (25.1 months vs. 14.8 months, p = 0.049). Moreover, the number of patients requiring blood transfusion was higher in the abiraterone group than in the enzalutamide group (9.1% vs. 26.3%, p = 0.16). The study also found that the number of doses of Radium-223 received was significantly associated with overall survival (≥5 vs. <5, HR 0.028, 95%CI 0.003-0.231, p = 0.001). Our study provides insights into the optimal treatment choice for mCRPC prior to radium-223, indicating that enzalutamide prior to radium-223 administration may have better outcomes compared to abiraterone in mCRPC patients without visceral metastasis.

Exogenous Cushing Syndrome and Hip Fracture Due to Over-the-Counter Supplement (Artri King)

The most common cause of Cushing syndrome (CS) is exposure to exogenous glucocorticoids. There is an increasing incidence of adulterated over-the-counter (OTC) supplements containing steroids. We present a case of Artri King (AK)-induced CS in a 40-year-old woman who presented with an intertrochanteric fracture of her right femur. Laboratory testing revealed suppressed cortisol and adrenocorticotropic hormone, which was consistent with suppression of the hypothalamic-pituitary-adrenal (HPA) axis. Following the cessation of the AK supplement, the patient's HPA axis recovered, and the clinical manifestations of CS improved. This case emphasizes the need for better regulation of OTC supplements and the need for cautious use.

Use of Systemic Steroids, Hormone Replacement Therapy, or Oral Contraceptives Is Associated with Decreased Implant Survival in Women

BACKGROUND

Systemic steroids, such as prednisone, hormonal replacement therapies, or oral contraceptives, are commonly prescribed to women who might also be receiving dental implant therapy. However, the effect of these medications on dental implant survival is unknown.

METHODS

The medical and dental records of individuals with dental implants (N = 1480 implants) who visited a postgraduate periodontics clinic between 2000 and 2017 were initially considered. Those younger than 21 years old, pregnant, or male were excluded according to the study's exclusion criteria. The presence of systemic diseases and conditions was assessed. Implant failure rates among female patients using systemic steroids, hormone replacement therapy, or oral contraceptives were compared with failure rates among patients not taking those medications.

RESULTS

The implant failure rate for the 65 implants in patients taking steroid medications was 7.69%; the failure rate for the 712 implants in patients not taking steroids was 1.54% (p < 0.001). After adjusting for smoking and the presence of diabetes, that relationship persisted, with an 8.47% implant failure rate for the 59 implants in patients taking steroids (vs. 1.54% failure for the 585 implants in patients not taking steroids; p < 0.001). Regression analyses demonstrated that the odds of implant failure versus success were 5.31 times greater in patients taking systemic steroids, hormone replacement therapy, or oral contraceptives (p < 0.05). No statistically significant differences in patient plaque control were found between the experimental and control groups.

CONCLUSIONS

Among women, the use of systemic steroids is associated with a five-fold increase in the rate of dental implant failure, regardless of the presence of smoking or diabetes.

Comparison of clinical outcome of lumbar spinal stenosis surgery in patients with and without osteoporosis: a prospective cohort study

BACKGROUND

Osteoporosis is one of the most important risk factors for failure of the spine instrumentation. Management of patients with osteoporosis who requires spinal surgery because of the difficulty in instrument placement and the potential complications is still a challenge. This study was designed to evaluate the clinical outcome of lumbar spinal canal stenosis after instrumentation in patients with and without osteoporosis.

METHODS

This prospective cohort study was performed from June 2018 to December 2020, in Be'sat Hospital, Hamadan, Iran. The sample consisted of patients over 50 years old referred to Be'sat Hospital with a diagnosis of lumbar spinal canal stenosis who underwent instrumental surgery (n = 107). Based on bone densitometry, the sample was divided into two groups with osteoporosis (n = 34) and without osteoporosis (n = 73). To collect data, we used a three-part researcher-made questionnaire (demographic information, medical records information, and paraclinical parameters). Statistical analyzes were performed by the Fisher Exact, chi-square, independent t-test, Multiple ANCOVA, Mann-Whitney and the Rank Wilcoxson tests using Stata version 17 software.

RESULTS

The mean age (SD) of patients in the two groups with and without osteoporosis was 67.9 (7.0) and 59.1 (5.1) years, respectively (p = 0.001). The results indicated that a significant difference was observed between the two groups in sex (p = 0.032), educational status (p = 0.001), marital status (p = 0.023), employment status (p = 0.004), menopausal status (p = 0.018), taking corticosteroids (p = 0.028), and body mass index (p = 0.015). Also, there was a significant difference between two groups in the loosening of instrument (p = 0.039), the postoperative pain intensity (p = 0.007), fusion (p = 0.047), and neurogenic claudication (p = 0.003). Based on multiple ANCOVA test, there was not a significant difference between two groups in the clinical and paraclinical charatecristics (p > 0.05). The mean (SD) of T-Score in the osteoporosis group was 3.06 (0.37).

CONCLUSION

This study provides evidence that there is no significant difference in the clinical outcomes of lumbar spine instrumentation due to spinal canal stenosis in patients with and without osteoporosis. Because of the high cost of specific instrumentation developed for patients with osteoporosis and their unavailability, it seems that the use of conventional instrumentation along with complete treatment of osteoporosis can help improve the clinical outcome of surgery in these patients.

Diosmin mitigates dexamethasone-induced osteoporosis in vivo: Role of Runx2, RANKL/OPG, and oxidative stress

Secondary osteoporosis is commonly caused by long-term intake of glucocorticoids (GCs), such as dexamethasone (DEX). Diosmin, a natural substance with potent antioxidant and anti-inflammatory properties, is clinically used for treating some vascular disorders. The current work targeted exploring the protective properties of diosmin to counteract DEX-induced osteoporosis in vivo. Rats were administered DEX (7 mg/kg) once weekly for 5 weeks, and in the second week, vehicle or diosmin (50 or 100 mg/kg/day) for the next four weeks. Femur bone tissues were collected and processed for histological and biochemical examinations. The study findings showed that diosmin alleviated the histological bone impairments caused by DEX. In addition, diosmin upregulated the expression of Runt-related transcription factor 2 (Runx2) and phosphorylated protein kinase B (p-AKT) and the mRNA transcripts of Wingless (Wnt) and osteocalcin. Furthermore, diosmin counteracted the rise in the mRNA levels of receptor activator of nuclear factor-kB ligand (RANKL) and the reduction in osteoprotegerin (OPG), both were induced by DEX. Diosmin restored the oxidant/antioxidant equilibrium and exerted significant antiapoptotic activity. The aforementioned effects were more pronounced at the dose level of 100 mg/kg. Collectively, diosmin has proven to protect rats against DEX-induced osteoporosis by augmenting osteoblast and bone development while hindering osteoclast and bone resorption. Our findings could be used as a stand for recommending supplementation of diosmin for patients chronically using GCs.