Statins and hip fracture prevention--a population based cohort study in women

Advantages of statin usage in preventing fractures for men over 50 in the United States: National Health and Nutrition Examination Survey

OBJECTIVES

The relationship between statin treatment and fracture risk is still controversial, especially in in patients with cardiovascular diseases (CVDs). We aim to determine whether statin therapy affects the occurrence of fractures in the general US population and in patients with CVDs.

METHODS

Epidemiological data of this cross-sectional study were extracted from the National Health and Nutrition Examination Survey (NHANES, 2001-2020, n = 9,893). Statins records and fracture information were obtained from the questionnaires. Weighted logistic regressions were performed to explore the associations between statin and the risk of fracture.

RESULTS

Statin use was found to be associated with reduced risk of fracture mainly in male individuals aged over 50 years old and taking medications for less than 3 years, after adjusted for confounders including supplements of calcium and vitamin D. The protective effects were only found in subjects taking atorvastatin and rosuvastatin. We found null mediation role of LDL-C and 25(OH)D in such effects. Statin was found to reduce fracture risk in patients with cardiovascular diseases (CVDs, OR: 0.4366, 95%CI: 0.2664 to 0.7154, P = 0.0014), and in patients without diabetes (OR: 0.3632, 95%CI: 0.1712 to 0.7704, P = 0.0091).

CONCLUSIONS

Statin showed advantages in reducing risk of fracture in male individuals aged over 50 years old and taking medications for less than 3 years. More research is needed to determine the impact of gender variations, medication duration, and diabetes.

Age- and dose-dependent effect of statin use on the risk of osteoporotic fracture in older adults

Previous studies have revealed the protective effects of statins on bone but the association of statins use with osteoporosis-related measurement has shown controversial results. In this study, we found an age, dose andduration-dependent osteoprotective effect of statins in general older population.

PURPOSE

Previous studies have revealed the protective effects of statins on bone but the association of statins use with osteoporotic fractures has shown controversial results.

METHODS

In this study with Korean National Health Insurance Service-Senior cohort database, a total of 365,656 elderly without previous history of osteoporosis and who were started on statin since January 1 2004 were included and observed until December 31 2012. Hazard rations (HR) for major osteoporotic fractures were calculated using the weighted Cox proportional hazards model with inverse-probability of treatment weighting method.

RESULTS

During 6.27 years of follow-up period, 54,959 osteoporotic fractures occurred and the majority of fractures (69.5%) were vertebral fractures. Compared with non-users, statin use was associated with a decreased risk of all outcomes with adjusted HR (95% CI) of 0.77 (0.72-0.83; P < 0.001) for major osteoporotic fractures, 0.49 (0.38-0.62; P < 0.001) for hip fractures, and 0.70 (0.64-0.77; P < 0.001) for vertebral fractures. When outcomes were examined separately by sex, the results were broadly comparable in terms of patterns of risk reduction by statin use. The patients with statin initiated at age ≥ 80 years had the highest risk reduction for most outcomes relative to non-users. Higher cumulative dose of statin was negatively associated with the osteoporotic fracture risk; 0.97 (0.91-1.02) for 30-364 cumulative daily defined dose (cDDD), 0.45 (0.40-0.51) for 365-1,094 cDDD, and 0.22 (0.15-0.33) for ≥ 1,095 cDDD.

CONCLUSIONS

Our results showed that statin use was associated with significant reduction in the risk of osteoporotic fractures in general older population.

Statin use in patients with type 2 diabetes has lower risk of hip fractures: A Taiwan national population-based study

AIMS

Type 2 diabetes mellitus (T2DM) frequently co-exists with osteoporosis and dyslipidemia. Statins have been commonly used in the treatment of dyslipidemia. Recent studies have indicated a therapeutic role of statins in decreasing the risk of osteoporosis and fractures, but conflicting results have been reported. This study investigated the association between statin use and hip fracture (HFx) risk among T2DM patients.

MATERIALS AND METHODS

A retrospective Taiwan population-based propensity-matched cohort study was performed using the Diabetes Mellitus Health Database from Taiwan National Health Insurance Research Database. Patients with newly diagnosed with T2DM between 2010 and 2014 were identified. Patients who previously used statins and had ever suffered HFx before the index date were excluded. HFx that occurred from 2010 to 2019 was collected to compute the cumulative rate of HFx. Hazard ratios (HRs) were calculated for the HFx risk according to the use or non-use of statins. To evaluate the dose-effect relationship of statins, sensitivity analyses were conducted.

RESULTS

After propensity score matching for age and sex, 188,588 patients were identified as statin users and non-statin users. Statin use after T2DM diagnosis was associated with a decreased HFx risk with an adjusted HR (aHR) of 0.69 (P < 0.001). A dose-effect relationship was identified. The aHRs for developing HFx were 1.29, 0.67, and 0.36 for patients who used 28-174, 175-447, and >447 cumulative defined daily doses of statins, respectively (P < 0.001).

CONCLUSIONS

Statin use in adults with T2DM showed a lower risk of HFx by demonstrating a dose-response relationship.

Effects of statins and aspirin on HCC risk in alcohol-related cirrhosis: nationwide emulated trials

BACKGROUND AND AIMS

Observational studies have shown an association between statin or aspirin use and a decreased risk of HCC, but the effects of a well-defined treatment strategy remain unknown. We emulated trials of the effects of continuous statin or aspirin use on HCC risk in patients with cirrhosis due to alcohol-related liver disease (ALD cirrhosis).

APPROACH AND RESULTS

We specified target trials for statins and, separately, aspirin and emulated them using Danish health care registries. All eligible patients with ALD cirrhosis diagnosed in 2000-2018 were included in either an exposed or an unexposed arm. Patients were followed until HCC or death without HCC. The 5-year risk of HCC was estimated using marginal structural models with inverse probability weighting. Using statins continuously for 5 years compared with not using statins resulted in a relative risk (RR) of HCC of 0.67 (95% CI: 0.45-0.91). The RR of death without HCC was 0.69 (95% CI: 0.65-0.77). For aspirin, the RR was 1.05 (95% CI: 0.60-1.42) for HCC and 1.02 (95% CI: 0.95-1.09) for death without HCC.

CONCLUSIONS

In patients with ALD cirrhosis, 5 years of continuous statin use resulted in a 33% RR reduction of HCC (number needed to treat = 94) and a 31% RR reduction of death without HCC (number needed to treat = 7). Such strong causal effects are implausible and best explained by uncontrollable confounding, highlighting the need for randomized trials. Aspirin use likely does not affect the risk of HCC or death without HCC.

Rationale and performances of a data-driven method for computing the duration of pharmacological prescriptions using secondary data sources

The assessment of the duration of pharmacological prescriptions is an important phase in pharmacoepidemiologic studies aiming to investigate persistence, effectiveness or safety of treatments. The Sessa Empirical Estimator (SEE) is a new data-driven method which uses k-means algorithm for computing the duration of pharmacological prescriptions in secondary data sources when this information is missing or incomplete. The SEE was used to compute durations of exposure to pharmacological treatments where simulated and real-world data were used to assess its properties comparing the exposure status extrapolated with the method with the “true” exposure status available in the simulated and real-world data. Finally, the SEE was also compared to a Researcher-Defined Duration (RDD) method. When using simulated data, the SEE showed accuracy of 96% and sensitivity of 96%, while when using real-world data, the method showed sensitivity ranging from 78.0 (nortriptyline) to 95.1% (propafenone). When compared to the RDD, the method had a lower median sensitivity of 2.29% (interquartile range 1.21–4.11%). The SEE showed good properties and may represent a promising tool to assess exposure status when information on treatment duration is not available.

A Retrospective Study on Statins and Post-stroke Patients: What About Functional Outcome and Follow-Up in a Stroke Rehabilitation Cohort?

Objective: Statins exert pleiotropic effects by influencing several mechanisms, including synaptogenesis, neurogenesis, cerebral flow regulation, and angiogenesis. Results from in vitro and animal models suggest that statins could have beneficial effect on functional recovery and outcome after stroke events. However, results in human studies are still controversial. The aim of our study was to evaluate the role of statin in influencing functional outcome and subsequent clinical follow-up in a large cohort of post-stroke rehabilitation patients.

Methods: This retrospective study consecutively enrolled 413 adult patients with stroke event, admitted to the division of Neurorehabilitation of the IRCCS ICS Maugeri, Veruno (Italy), for an individual rehabilitation program between 2015 and 2017. Follow-up lasted 3–5 years after discharge. Demographic data, etiology, classification, and anatomical site of stroke lesion, functional assessment, use and duration of statin therapy, and death during hospitalization were collected at baseline and on discharge. Clinical data on subsequent follow-up were also evaluated, considering these as variables: stroke recurrence, bone fractures, cardiovascular complications, and death.

Results: In our cohort, 177 patients (42.9%) were prescribed statin therapy, of whom 50 (28.2%) before the stroke event and 127 (71.8%) at the beginning of the rehabilitation process. The use and type of statin therapy as well as the duration of treatment were not associated with recovery and functional outcome, regardless of confounders including sex, age, etiology, and site of stroke lesion, and initial functional level. For what concern post-discharge clinical follow-up, the use of statin therapy was significantly associated with a lower risk of bone fractures (OR = 0.095, CI 95%: 0.012–0.743, p = 0.01) independently from age, sex, initial and final functional level, and comorbidities.

Conclusions: The use of statins does not seem to influence the functional outcome in post-stroke patients. However, they could exert a protective role against bone fractures during post-discharge follow-up, suggesting further evaluation on this topic.

The associations of statin intake and the trabecular bone score and bone mineral density status in elderly Iranian individuals: a cross-sectional analysis of the Bushehr Elderly Health (BEH) program

In recent years, a growing interest on the impact of statin intake on bone health has emerged, although the reported results are controversial. The results of this study revealed that BMD at lumbar spine has a significant association with statin intake. However, such association appears to be weaker regarding TBS values compared to BMD. This study was performed with the aim of evaluating associations of statin intake with BMD and TBS using data from 2426 individuals aged ≥ 60 years from the second phase of the Bushehr Elderly Health (BEH) program. We found a positive association between statin and BMD at lumbar spine, whereas association between statin and TBS was detected only in the men in the final model.

INTRODUCTION

In recent years, a growing interest has been established to evaluate the impact of statin intake on bone health, although the reported results are controversial. This study aimed to evaluate the association of statin intake with bone health status according to BMD and TBS.

METHODS

This cross-sectional analysis used data from the elderly Iranian individuals who participated in the Bushehr Elderly Health (BEH) program. Dual x-ray absorptiometry (DXA) device was used to evaluate the BMD at lumbar spine (L1-L4), femoral neck, and total hip, as well as TBS at lumbar spine.

RESULTS

Among 2426 (1260 women and 1166 men) study participants, 778 were statin users. A positive significant association, irrespective of sex, was observed between statin intake and BMD at L1-L4, even after controlling for potential variables in total population (β = 0.016, p = 0.013). The mean TBS values at L1-L4 were negatively associated with statin intake in total population (β =  - 0.009, p = 0.001), while in the full adjusted model, significant positive association between TBS and statin intake was detected only in men (β = 0.013, p = 0.02).

CONCLUSION

The results of this study revealed that BMD at lumbar spine has a significant association with statin intake. However, such an association appears to be weaker regarding TBS values compared to BMD.

Statin Therapy and the Risk of Osteoporotic Fractures in Patients with Metabolic Syndrome: a Nested Case-Control Study

OBJECTIVE

We aimed to investigate the association between statin use and the risk of major osteoporotic fractures in patients with metabolic syndrome (MetS).

METHODS

A nested case-control study was performed in patients with MetS (≥50 years) who had no history of osteoporotic fracture using the Korean National Health Insurance Service-Health Screening Cohort. This study included 17,041 patients diagnosed with new-onset osteoporotic fractures and controls matched in a 1:1 ratio by age, sex, body mass index, cohort entry date, and follow-up duration. Conditional logistic regression analysis was used to evaluate covariate-adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

During a 4-year follow-up period, the risk of major osteoporotic fractures was significantly reduced by 9% (OR, 0.91; 95% CI, 0.85-0.97) in statin users compared with that in non-users. Among subtypes of major osteoporotic fracture, a risk reduction with statin therapy was significant for vertebral fracture (OR, 0.86; 95% CI, 0.79-0.94) but not for non-vertebral fracture (OR, 0.97; 95% CI, 0.88-1.06). Longer duration (OR, 0.97; 95% CI, 0.96-0.99, per 1-year increase) and higher cumulative dose (OR, 0.97; 95% CI, 0.95-0.99, per 365 defined daily doses) of statins were negatively associated with the risk of major osteoporotic fracture.

CONCLUSION

This study supports the hypothesis that statin therapy has a beneficial effect on major osteoporotic fractures, especially vertebral fractures, in patients with MetS.

Risk of fracture incidence in prostate cancer survivors: a nationwide cohort study in South Korea

PURPOSE

We analyzed the risk of fracture in prostate cancer (PC) survivors compared to that in the general population in South Korea and according to the primary treatment.

METHODS

From 2007 to 2013, a total of 41,733 PC survivors newly diagnosed with PC in South Korea were identified and matched to non-cancer controls. Cox proportional hazards regression analysis was performed to determine the relative risk of fracture.

RESULTS

Compared to the matched controls, PC survivors had a higher risk of fracture (adjusted hazard ratio (aHR) 1.39; 95% confidence interval (CI) 1.33-1.45). Compared to the matched controls, the active surveillance/watchful waiting and radiotherapy group showed a similar risk of fracture (aHR 1.08; 95% CI 0.98-1.20, and aHR 1.04; 95% CI 0.63-1.73, respectively). PC survivors who underwent surgery showed a lower risk of fracture (aHR 0.89; 95% CI 0.82-0.96), while those who underwent surgery + androgen deprivation therapy (ADT) (aHR 1.41; 95% CI 1.26-1.57), radiotherapy + ADT (aHR 1.86; 95% CI 1.50-2.32), and only ADT (aHR 1.92; 95% CI 1.82-2.02) showed a higher risk of fracture than the control group.

CONCLUSION

The risk of fracture differed according to the primary treatment method for PC; survivors who underwent surgery had a lower risk of fracture compared to that of the general population. However, PC survivors treated with ADT showed a higher risk of fracture than the other PC treatment groups or the general population. Therefore, more attention and preventive bone care are required for PC survivors who receive ADT.

Is Switching from Oral Antidiabetic Therapy to Insulin Associated with an Increased Fracture Risk?

BACKGROUND

Observational studies showed that exposure to exogenous insulin increases fracture risk. However, it remains unclear whether the observed association is a function of the severity of underlying type 2 diabetes mellitus, complications, therapies, comorbidities, or all these factors combined. That being so, and because of the relative infrequency of these events, it is important to study this further in a large-database setting. QUESTION/PURPOSES: (1) Is switching from oral antidiabetic agents to insulin associated with an increased fracture risk? (2) How soon after switching does the increased risk appear, and for how long does this increased risk persist?

METHODS

Data from healthcare utilization databases of the Italian region of Lombardy were used. These healthcare utilization databases report accurate, complete, and interconnectable information of inpatient and outpatient diagnoses, therapies, and services provided to the almost 10 million residents in the region. The 216,624 patients on treatment with oral antidiabetic therapy from 2005 to 2009 were followed until 2010 to identify those who modified their antidiabetic therapy (step 1 cohort). Among the 63% (136,307 patients) who experienced a therapy modification, 21% (28,420 patients) switched to insulin (active exposure), and the remaining 79% (107,887 patients) changed to another oral medication (referent exposure). A 1:1 high-dimension propensity score matching design was adopted for balancing patients on active and referent exposure. Matching failed for 3% of patients (926 patients), so the cohort of interest was formed by 27,494 insulin-referent couples. The latter were followed until 2012 to identify those who experienced hospital admission for fracture (outcome). A Cox proportional hazard model was fitted to estimate the hazard ratio (HR) for the outcome risk associated with active-exposure (first research question). Between-exposure comparison of daily fracture hazard rates from switching until the 24 successive months was explored through the Kernel-smoothed estimator (second research question).

RESULTS

Compared with patients on referent exposure, those who switched to insulin had an increased risk of experiencing any fracture (HR = 1.5 [95% CI 1.3 to 1.6]; p < 0.001). The same risk was observed for hip and vertebral fractures, with HRs of 1.6 (95% CI 1.4 to 1.8; p < 0.001) and 1.8 (95% 1.5 to 2.3; p < 0.001), respectively. Differences in the daily pattern of outcome rates mainly appeared the first 2 months after switching, when the hazard rate of patients on active exposure (9 cases for every 100,000 person-days) was higher than that of patients on referent exposure (4 cases for every 100,000 person-days). These differences persisted during the remaining follow-up, though with reduced intensity.

CONCLUSIONS

We found quantitative evidence that switching from oral antidiabetic therapy to insulin is associated with an increased fracture risk, mainly in the period immediately after the start of insulin therapy. The observed association may result from higher hypoglycemia risk among patients on insulin, which leads to a greater number of falls and resulting fractures. However, although our study was based on a large sample size and highly accurate data, its observational design and the lack of clinical data suggest that future research will need to replicate or refute our findings and address the issue of causality, if any. Until then, though, prescribers and patients should be aware of this risk. Careful control of insulin dosage should be maintained and measures taken to reduce fall risk in these patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Effects of Statins on Relative Risk of Fractures for Older Adults: An Updated Systematic Review With Meta-Analysis

OBJECTIVES

Basic and translational studies have found statin treatment may have beneficial effects on bone metabolism; however, whether statins reduce the risk of fractures in older adults is still in debate. Therefore, we aimed to summarize the up-to-date evidence on risk of fracture among older individuals with statin use.

DESIGN

Systematic literature review and meta-analysis.

SETTING AND PARTICIPANTS

Twenty-one observational studies and 2 randomized controlled trials (RCTs) comprising 1,783,123 participants aged at least 50 years were retrieved from PubMed, Embase, and the Cochrane Library.

MEASURES

We estimated summary relative risks (RRs) with 95% confidence intervals (CIs) using the random-effects model. Subgroup analysis was performed to explore the potential source of heterogeneity.

RESULTS

Meta-analysis of observational studies suggested that statin treatment was significantly associated with reduced risk of all fractures (RR 0.80, 95% CI 0.72-0.88), among which hip fracture (RR 0.73, 95% CI 0.64-0.82) and lower extremity fracture (RR 0.69, 95% CI 0.54-0.88) showed consistent results, whereas no significant decreased risk was observed with respect to other fracture sites. Subgroup analyses showed that among the statin users, fracture risk was reduced in both genders, older adults ≥50 years old, those with short drug duration (< year) or medium to high statin dose (>90 defined daily dose), those taking atorvastatin, and in Europeans and Americans. Meta-analysis of RCTs revealed no significant effect of statin treatment on the risk of fractures (RR 1.00, 95% CI 0.87-1.15).

CONCLUSIONS AND IMPLICATIONS

Overall, the findings of this updated meta-analysis indicated no solid evidence supporting that statins have a beneficial effect associated with reduced risk of fractures for older adults. Our findings should be further confirmed in future larger population-based prospective cohort studies or well-designed RCTs.

Methods for constructing treatment episodes and impact on exposure-outcome associations

PURPOSE

To assess the impact on exposure time and outcome misclassifications, and consequent impact on exposure-outcome associations from treatment episode construction. We investigated the dosage assumptions of 1 unit per day, and 1 DDD per day, versus actual prescribed dosage under different handling of gaps and overlaps of prescriptions.

METHODS

Data on mirtazapine and citalopram exposure (years 2006-2014) from the Swedish Prescribed Drug register were used. Via a within individuals design we compared method A, based on actual dosage, with methods B and C based on 1 unit of drug per day and 1 DDD per day assumptions, respectively, including consideration of gaps and overlaps. Four outcomes were used, hospitalizations and outpatient visits for all and for psychiatric causes.

RESULTS

Relative to method A, both alternative methods lead to misclassification of exposure time. With regard to outcome misclassifications, method B overestimates the effect of the exposure on the outcome in 77% and 100% of exposure definition comparisons for mirtazapine and citalopram respectively, while 23% of the comparisons for mirtazapine results in underestimation of exposure-outcome associations. Conversely, treatment episodes based on DDD (method C) result in underestimation of the exposure-outcome association in 100% and 87.5% of exposure definition comparisons for mirtazapine and citalopram respectively, while 12.5% of the comparisons for citalopram results in overestimation of the exposure-outcome associations.

CONCLUSIONS

The study provides results that have consistent clinical relevance. We have showed that a non-accurate construction of exposure time may lead to errors on outcome detection during exposed time, and consequently affect conclusions on safety or efficacy profile of a treatment.

Long-term effect of statins on the risk of new-onset osteoporosis: A nationwide population-based cohort study

BACKGROUND

Several observational cohort and meta-analytical studies in humans have shown that statin users have a lower risk of fractures or greater bone mineral densities (BMD) than nonusers. However, some studies including randomized clinical trials have the opposite results, particularly in Asian populations.

OBJECTIVE

This study investigates the impacts of statins on new-onset osteoporosis in Taiwan.

METHODS

In a nationwide retrospective population-based cohort study, 45,342 subjects aged between 50-90 years having received statin therapy (statin-users) since January 1 2001, and observed through December 31 2013 were selected from the National Health Insurance Research Database of Taiwan. Likewise, 115,594 patients had no statin therapy (statin-non-users) were included as controls in this study. Multivariable Cox proportional hazards analysis for drug exposures was employed to evaluate the association between statin treatment and new-onset of osteoporosis risk. We also used the long-rank test to evaluate the difference of probability of osteoporosis-free survival.

RESULTS

During the 13-year follow-up period, 16,146 of all enrolled subjects (10.03%) developed osteoporosis, including 3097 statin-users (6.83%) and 13,049 statin-non-users (11.29%). Overall, statin therapy reduced the risk of new-onset osteoporosis by 48% (adjusted hazard ratio [HR] 0.52; 95% CI 0.50 to 0.54). A dose-response relationship between statin treatment and the risk of new-onset osteoporosis was observed. The adjusted hazard ratios for new-onset osteoporosis were 0.84 (95% CI, 0.78 to 0.90), 0.56 (95% CI, 0.52 to 0.60) and 0.23 (95% CI, 0.21 to 0.25) when cumulative defined daily doses (cDDDs) ranged from 28 to 90, 91 to 365, and more than 365, respectively, relative to nonusers. Otherwise, high-potency statins (rosuvastatin and atorvastatin) and moderate-potency statin (simvastatin) seemed to have a potential protective effect for osteoporosis.

CONCLUSIONS

In this population-based cohort study, we found that statin use is associated with a decreased risk of osteoporosis in both genders. The osteoprotective effect of statins seemed to be more prominent with a dependency on the cumulative dosage and statin intensity.

High-potency statins but not all statins decrease the risk of new-onset osteoporotic fractures: a nationwide population-based longitudinal cohort study

BACKGROUND

Statins have been linked to new-onset osteoporotic fractures (NOFs), and different statins may alter the risk for the development of NOFs.

AIM

In this study, we investigated the association between different statins and the development of NOFs.

PATIENTS AND METHODS

This was a longitudinal cohort study performed using data from claim forms submitted to the Taiwan Bureau of National Health Insurance, including case patients with NOFs from January 2004 to December 2013 and non-NOF subjects. We estimated the hazard ratios (HRs) of NOFs associated with statin use. Nonuser subjects served as the reference group.

RESULTS

A total of 44,405 patients with NOFs were identified from among 170,533 patients with hyperlipidemia during the study period. The risk of developing NOFs after adjusting for age, sex, comorbidities, and concurrent medication use was lower among users of atorvastatin (HR, 0.77; 95% CI, 0.71-0.84) and rosuvastatin (HR, 0.72; 95% CI, 0.64-0.81) than among simvastatin users. Lovastatin, pravastatin, fluvastatin, and pitavastatin were not associated with the risk of developing NOFs compared with simvastatin users.

CONCLUSION

This study supports previous reports regarding a beneficial effect of statin use and NOF risk, but not all statins. Patients taking atorvastatin or rosuvastatin were at lower risk of developing NOFs compared with simvastatin users during the 10-year follow-up. Other statins such as pravastatin, fluvastatin, lovastatin, and pitavastatin were not associated with NOFs. This study also highlighted that high-potency statin has a dose-response effect on lower NOF risk.

The Relationship of Pulse Pressure and Bone Mineral Density in Adult USA Population: Analysis of the National Health and Nutritional Examination Survey

BACKGROUND/PURPOSE

Accumulating evidence indicates a relationship between Cardiovascular Disease (CVD) and osteoporosis. Hypertension, a known risk factor for CVD is also associated with low Bone Mineral Density (BMD). We hypothesize that Pulse Pressure (PP); a CVD risk factor is associated with BMD.

METHODS

Data from two consecutive cycles of National Health and Nutritional Examination Survey (NHANES) from 2009-2010 and 2011-2012. Point estimates of demographic variables were calculated using descriptive methods. Study participants were divided into 4 groups based on quartile distribution of PP. Multivariate linear regression analysis was performed to assess the relationship between BMD and PP.

RESULTS

A total of 8,179 NHANES participants were included in the study (Tables 1-3). The cohort's mean age (± SE) was 53.3 years 0.19, mean BMI (± SE) 29.6 kg/m² ± 0.07. PP was significantly higher with increased age, among Blacks (57.4 ± 0.52) and Hispanics (57.5 ± 0.19) compared to whites (53.9 ± 0.29), and for men (57.2 ± 0.16) when compared to women (54.1 ± 0.17), p<0.05. After adjusting for age, sex, race, menopause, body mass index, family history of osteoporosis, PP was associated with femoral neck BMD, β=-0.0005, p<0.05 but was not significantly associated with lumbar spine BMD, β=-0.0002, p=0.07.

CONCLUSION

Our results support the hypothesis that wide PP is associated with low BMD. This negative association was demonstrated at the femoral neck where bone loss and osteoporotic fractures occur at a more advanced stage, further supporting the relationship between atherosclerosis and osteoporosis risk. These findings have the potential for identifying high osteoporotic risk patients among those with wide pulse pressure, providing further indications for bone mineral density testing among these elderly frail patients. Further research is needed to investigate the mechanisms behind the relationship between PP and BMD.

Statin use and hip fractures in U.S. kidney transplant recipients

Background

Basic and translational research supports beneficial effects of statins on bone metabolism. Clinical studies suggest that statin use may reduce the risk of hip fractures in the general population. Whether statin use is associated with hip fracture risk in kidney transplant recipients, a particularly high-risk group for this outcome, is unknown.

Methods

From the U.S. Renal Data System (2007–2011), we identified all hip fracture events recorded in Medicare billing claims of first-time kidney transplant recipients. We then matched all cases to an unlimited number of controls on age (±3 years), sex, race (black vs. non-black), and time since transplant. Cases and controls were required to have >1 year of Medicare Parts A + B + D coverage and be without a recorded history of hip fracture. We ascertained any statin use in the previous year and defined adherent statin use as those who had filled prescriptions for statins to cover >80% of days in that year (proportion of days covered, PDC). We ascertained several potential confounders (demographics, comorbidities, BMI, transplant-related factors) and applied conditional logistic regression with multiple imputation for missing data to estimate odds ratios (OR) and 95% confidence intervals (CI).

Results

We identified 231 hip fracture cases (mean age 51.8 years; 53% female; 11.3% black; 6.9 years from transplant, and 9.9 years from ESRD) and 15,575 matched controls. Any prior statin use was present in 64.1% of cases and 60.3% of controls with 37.2% of cases and 33.9% of controls being found adherent. Unadjusted conditional logistic regression showed an OR of 1.17 (0.89-1.54) for any statin use, and a fully-adjusted OR of 0.89 (0.67-1.19). Compared with statin non-users, the adjusted OR for patients with lesser adherence (PDC ≤80%) and those with greater adherence (PDC >80%) were 0.93 (0.66-1.31) and 0.87 (0.63-1.20), respectively.

Conclusion

Statin use was not associated with hip fracture risk in first-time kidney transplant recipients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-017-0559-9) contains supplementary material, which is available to authorized users.

Exposure to statins is associated to fracture risk reduction in elderly people with cardiovascular disease: evidence from the AIFA-I-GrADE observational project

PURPOSE

Conflicting findings were observed from clinical trials and observational studies evaluating the association between the use of statins and the risk of fracture. A case-control study nested into a cohort of elderly patients on treatment with statins for cardiovascular secondary prevention was performed on this issue.

METHODS

The cohort was formed by 13 875 individuals aged ≥65 years from several Italian health units receiving statins after hospital discharge for cardiovascular outcomes. From this cohort, 964 patients who experienced fracture were identified (i.e., cases). Up to five controls were randomly selected for each case from the underlying cohort. Conditional logistic regression was used to model the risk of fracture associated with adherence to statins, which was measured from the proportion of days covered (PDC) by treatment. A set of sensitivity analyses was performed in order to account for sources of systematic uncertainty.

RESULTS

Compared with patients with low adherence (PDC ≤ 40%), those on intermediate (PDC 41-80%) and high (PDC > 80%) adherence exhibited a risk reduction of 21% (95% confidence interval 6% to 23%) and 25% (7% to 40%). Similar effects were observed among patients younger and older than 80 years, as well as among men, while there was no evidence that adherence to statins affected the risk of fracture among women. Sensitivity analyses revealed that the associations were consistent and robust.

CONCLUSIONS

Use of statins for secondary cardiovascular prevention is associated with fracture risk reduction in elderly people. Further studies are required to better clarify the statin-fracture association in postmenopausal women. Copyright © 2017 John Wiley & Sons, Ltd.

Efficacy of statins for osteoporosis: a systematic review and meta-analysis

Our meta-analysis assessed the efficacy of statins on the risk of fracture, bone mineral density (BMD), and the markers of bone metabolism by collecting data from 33 clinical trials. We found that statin treatment was associated with bone metabolism. And statins seemed to be more effective on male patients with osteoporosis. The efficacy of statins for the treatment of osteoporosis has been controversial in previous studies and meta-analyses. Our meta-analysis was conducted to examine in detail the efficacy of statins on osteoporosis. We searched PubMed, Embase, and the Cochrane Library databases for clinical trials from inception to May 2016. We included studies that described the effect of statins on the risk of fracture, BMD, or bone turnover markers. Moreover, we also conducted subgroup analyses according to the skeleton site, patient gender, and length of follow-up. A total of 33 studies which included 23 observational studies (16 cohort studies and 7 case-control studies) and 10 randomized controlled trials (RCTs) were evaluated. These 33 studies included 314,473 patients in statin group and 1,349,192 patients in control group. Statins decreased the risk of overall fractures (OR = 0.81, 95% CI 0.73-0.89) and hip fractures (OR = 0.75, 95% CI 0.60-0.92). Furthermore, the use of statins was associated with increased BMD at the total hip (standardized mean difference (SMD) = 0.18, 95% CI 0.00-0.36) and lumbar spine (SMD = 0.20, 95% CI 0.07-0.32) and improved the bone formation marker, osteocalcin (OC) (SMD = 0.21, 95% CI 0.00-0.42). However, there was no positive effect on vertebral fractures, upper extremity fractures, BMD at the femoral neck, bone-specific alkaline phosphatase (BALP), and serum C-terminal peptide of type I collagen (S-CTX). Also, compared with male subgroups, the effect on female subgroups was only slightly positive or of no statistical significance. Our meta-analysis indicates that statin treatment may be associated with a decreased risk of overall fractures and hip fractures, an increased BMD at the total hip, BMD at the lumbar spine, and OC. Moreover, our results also show that statin treatment may have a greater effect on male patients than on female patients.

Discontinuation of simvastatin leads to a rebound phenomenon and results in immediate peri-implant bone loss

Although administration of simvastatin has been reported to promote bone formation, the effect of short-term simvastatin administration is not well known. Following implant installation, 10-week-old male Wistar rats (n = 24) were divided into two groups randomly. The experimental group received 10 mg/kg of simvastatin daily for seven days. Then simvastatin administration was discontinued, and the animals were observed up to 28 days. Animals in the control group underwent the same procedure but received saline instead of simvastatin. All animals were analyzed by micro-computed tomography. Samples at days 14 and 21 were subjected to histological analyses. After seven days of simvastatin administration, more new bone formation around the implant was observed in the simvastatin group compared with the control group. Seven days after simvastatin discontinuation, however, the amount of peri-implant trabecular bone began to decrease. Results from morphometric analysis also showed a reduction in new bone area after day 7, which was lowest at day 14. These results were confirmed by histological analyses. In contrast, both the peri-implant trabecular bone and new bone area were maintained in the control group. Short-term administration of simvastatin may affect implant stability owing to a rebound phenomenon and an immediate loss of peri-implant bone.

Effects of Statins on Bone Mineral Density and Fracture Risk: A PRISMA-compliant Systematic Review and Meta-Analysis

Although observational studies have identified the protective effect of statins on bone health, the effects remain controversial in randomized controlled trials (RCTs). We conducted a meta-analysis of RCTs to evaluate the effects of statins on bone mineral density (BMD) and fracture risk among adults.We searched electronic databases of Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) and conducted a bibliography review to identify articles published until May, 2015.Studies included in this meta-analysis should be randomized controlled trials conducted in adults, using statins in the intervention group. Information on changes in BMD or odds ratio, relative risk or hazard ratio (HR) for fracture risk with the corresponding 95% confidence interval (CI) was provided.Two investigators independently reviewed the title or abstract, further reviewed the full-texts and extracted information on study characteristics and study outcomes. Net change estimates of BMD and pooled HR of fracture risk comparing the intervention group with the control group were estimated across trials using random-effects models.Of the relevant 334 citations, 7 trials (including 27,900 randomized participants in total) meeting the eligibility criteria were included. Of the 7 trials, 5 were conducted to assess the association of statins use with BMD change and 2 with fracture risk. Compared with the control group, statins use was associated with significant increase in BMD of 0.03 g/cm (95% CI: 0.006, 0.053; I = 99.2%; P < 0.001), but null association with fracture risk, with the pooled HR of 1.00 (95% CI: 0.87, 1.15; I = 0; P = 0.396). Sensitivity analyses revealed that the associations were consistent and robust.The effect of statins use on bone health among subpopulation could not be identified due to limited number of trials.These findings provide evidence that statins could be used to increase BMD other than decreasing fracture risk in participant with dyslipidemia. In addition, further trials with the primary outcome of bone health-related measurements in subpopulation are warranted to ensure the effect of statins use.

Statins and hip fracture risk in men: a population-based case-control study

PURPOSE

To estimate the association between hydroxymethylglutaryl-CoA inhibitor (statin) use and hip fracture.

METHODS

We conducted a population-based case-control study. Cases were 6774 male enrollees in a large managed care organization, aged 45 or more years, with an incident hip fracture from 1997 to 2006. Controls without fracture (n = 6774) were matched to cases on age, race, and medical center. Electronic information on pharmaceutical use was used to identify the dispensing of statins from 1991 forward.

RESULTS

Overall, 1884 (27.8%) cases and 2150 controls (31.7%) used a statin before index date (matched odds ratio [mOR] = 0.81, 95% confidence interval [CI] = 0.74-0.87). Adjustment for comorbidity burden strengthened the magnitude of the overall association (mOR = 0.68, CI = 0.62-0.74). The adjusted association was similar across age groups but was strongest among men aged 80 years or more (mOR = 0.62, CI = 0.54-0.71) and was most pronounced in African Americans (mOR = 0.43, CI = 0.28-0.64). Greater duration of statin use did not alter the odds ratios.

CONCLUSIONS

These data add to the growing evidence of a potential protective effect of statin use on bone health. However, these results need to be replicated in a prospective study that can account for confounding by indication which may explain these findings.

Statin therapy and risk of fracture: results from the JUPITER randomized clinical trial

IMPORTANCE

Osteoporosis and cardiovascular disease may share common biological pathways, with inflammation playing a role in the development of both. Although observational studies have suggested that statin use is associated with a lower risk of fractures, randomized trial data addressing this issue are scant.

OBJECTIVE

To determine whether statin therapy reduces the risk of fracture and, in a secondary analysis, whether baseline levels of the inflammatory biomarker high-sensitivity C-reactive protein (hs-CRP) are associated with the risk of fracture.

DESIGN, SETTING, AND PARTICIPANTS

The JUPITER (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) trial was an international, randomized, double-blind, placebo-controlled study enrolling 17,802 men older than 50 years and women older than 60 years with hs-CRP level of at least 2 mg/L. Participants were screened from 2003 to 2006 and observed prospectively for up to 5 years (median follow-up, 1.9 years).

INTERVENTION

Rosuvastatin calcium, 20 mg daily, or placebo.

MAIN OUTCOMES AND MEASURES

Incident fracture was a prespecified secondary end point of JUPITER. Fractures were confirmed by radiographs, computed tomography, bone scan, or other methods. Cox proportional hazards models were used to calculate hazard ratios (HRs) and associated 95% confidence intervals for the risk of fracture according to randomized treatment assignment, as well as increasing tertiles of hs-CRP, controlling for potential confounders.

RESULTS

During the study, 431 incident fractures were reported and confirmed. Among participants allocated to rosuvastatin, 221 fractures were confirmed, compared with 210 among those allocated to placebo, such that the incidence of fracture in the rosuvastatin and placebo groups was 1.20 and 1.14 per 100 person-years, respectively (adjusted HR, 1.06 [95% CI, 0.88-1.28]; P = .53). Overall, increasing baseline hs-CRP level was not associated with an increased risk of fractures (adjusted HR for each unit increase in hs-CRP tertile, 1.06 [95% CI, 0.94-1.20]; P for trend, .34).

CONCLUSIONS AND RELEVANCE

Among men and women with elevated hs-CRP level enrolled in a large trial of rosuvastatin therapy for cardiovascular disease, statin therapy did not reduce the risk of fracture. Higher baseline hs-CRP level was not associated with an increased risk of incident fracture.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00239681.

Cost-effectiveness of statin treatment for primary prevention in conditions of real-world adherence--estimates from the Finnish prescription register

OBJECTIVE

To estimate the cost-effectiveness of statin therapy for primary prevention of coronary heart disease (CHD) events under real-world adherence.

METHODS

A cost-effectiveness model was applied to estimate the expected 10-year costs and health outcomes (in terms of quality-adjusted life-years, QALYs) associated with and without statin treatment (at defined adherence levels) among hypothetical cohorts of Finnish men and women who were initially without established CHD. Treatment efficacy, cost, and quality of life estimates were obtained from published sources. Long-term treatment adherence was measured based on data from the national prescription register.

RESULTS

At an assumed willingness-to-pay threshold of €20,000 per QALY gained, statin treatment with real-world adherence was cost-effective among the older patient groups when the patients' 10-year CHD risk was as high as 20% and did not seem cost-effective in the youngest age groups. Conversely, statin treatment with full adherence was cost-effective for almost all patient groups with a 10-year CHD risk of at least 15%.

CONCLUSIONS

Even though generic statins are now low-cost drugs, treatment adherence seems to have a major impact on the cost-effectiveness of statin treatment in primary prevention. This finding stresses the importance of making a concerted effort for improving adherence among patients on statin therapy to obtain full benefit of the investment in statins. Therefore, novel cost-effective approaches to improve treatment adherence are warranted.

Melatonin potentiates the anti-tumour effect of pravastatin in rat mammary gland carcinoma model

Previous studies in the field of cancer research have suggested a possible role for statins in the reduction of risk in certain malignancies. The purpose of these studies was to examine the chemopreventive effects of pravastatin alone and in combination with pineal hormone melatonin in the N-methyl-N-nitrosourea-induced mammary carcinogenesis model. Pravastatin was given orally (1 00 mg/kg) and melatonin was added to the water (20 μg/ml). Chemoprevention began seven days prior to carcinogen administration and subsequently continued for 15 weeks until autopsy. At autopsy, mammary tumours were removed and prepared for histopathological and immunohistochemical analysis. Parameters of experimental carcinogenesis, mechanism of action (biomarkers of apoptosis, angiogenesis and proliferation) and side effects after long-term treatment in animals were assessed. Pravastatin alone suppressed tumour frequency by 20.5% and average tumour volume by 15% compared with controls. Combined administration of the drugs decreased tumour frequency by 69% and lengthened tumour latency by nine days compared with control animals. The ration between high and low grade carcinomas was apparently reduced in both treated groups. The analysis of carcinoma cells showed significant expression increase in caspase-3 and caspase-7 after pravastatin treatment; however, combined treatment even more pronounced increase in the expression of both caspases. Regarding VEGFR-2 expression, a small effect in carcinomas of both treated groups was found. In plasma metabolism evaluation, pravastatin alone significantly decreased levels of glucose and triacylglycerols. Our results suggest a mild anti-neoplastic effect of pravastatin in this rat mammary gland carcinoma model. Statins co-administered with other suitable drug (e.g. melatonin) should be further evaluated for tumour-preventive properties.

Association of Statins and Risk of Fractures in a Military Health System

Background: Contradictory evidence exists regarding statin use and risk of osteoporotic fractures. Objective: The study objective was to examine the effect of statins on fracture risk in a Military Healthcare System (MHS) with similar access and standard of health care for its beneficiaries. Methods: This is a retrospective study of patients enrolled in an MHS encompassing the period from October 1, 2003, to March 1, 2010. Statin users were defined as those receiving a statin for ≥90 days in Fiscal Year 2005, whereas nonusers were defined as individuals not receiving a statin throughout the study period. A propensity score–matched cohort of statin users and nonusers was created using 42 variables. The outcomes were identified using ICD-9-CM codes in the follow-up period (October 1, 2006, to March 1, 2010). In all, 4 outcomes were examined: all fractures, femoral neck fractures, upper-extremity fractures, and lower-extremity fractures. Results: Of 46 249 patients, 6967 pairs of statin users and nonusers were matched. Statin users had a lower risk of femoral neck fracture in comparison to nonusers (odds ratio = 0.58, 95% CI = 0.36-0.94) but similar risk of all fractures, lower-extremity fractures, and upper-extremity fractures. Conclusions: In this cohort of patients managed in an MHS, statin use was associated with a lower risk of femoral neck fractures, but not all fractures, upper-extremity fractures, or lower-extremity fractures.

Hyperlipidemia compromises homing efficiency of systemically transplanted BMSCs and inhibits bone regeneration

PURPOSE

Mesenchymal stem cells (MSCs) can selectively home to bone defects and play an essential role in promoting bone regeneration. As an adverse effect factor for bone metabolism, hyperlipidemia significantly impairs bone regeneration. In this study, bone marrow stromal cells (BMSCs) were systemically transplanted into a hyperlipidemic mouse model to explore the effect of hyperlipidemia on stem cell recruitment and bone regeneration.

METHODS

Hyperlipidemia was established in ApoE-/- mice (on C57BL/6J background) fed with a high fat diet (HFD) for five weeks. C57BL/6 mice fed with the same diet served as controls. BMSCs labeled with the green fluorescent protein (GFP) were then injected via the tail vein and bone defects were created in the mandibles. The animals were sacrificed at weeks 1, 2 and 4 after surgery, and the fate of the transplanted BMSCs was monitored with a fluorescence microscope and immunohistochemical analysis. After hematoxylin and eosin (HE) staining and Masson's Trichrome (MT) staining, histomorphometric analysis was performed to evaluate bone regeneration.

RESULTS

In both groups transplanted with BMSCs, the number of GFP-positive BMSCs detected in the bone defects reached its peak at 1 week after surgery and was decreased thereafter. However, at all time points, less GFP+ cells were detected in the ApoE-/- mice than in the corresponding control mice. BMSCs transplantation significantly enhanced new bone formation, but to a lesser degree in the ApoE-/- mice when compared with the control mice.

CONCLUSIONS

Hyperlipidemia compromises homing efficiency of systemically transplanted BMSCs and inhibits bone regeneration.

Delivery of small molecules for bone regenerative engineering: preclinical studies and potential clinical applications

Stimulation of bone regeneration using growth factors is a promising approach for musculoskeletal regenerative engineering. However, common limitations with protein growth factors, such as high manufacturing costs, protein instability, contamination issues, and unwanted immunogenic responses of the host reduce potential clinical applications. New strategies for bone regeneration that involve inexpensive and stable small molecules can obviate these problems and have a significant impact on the treatment of skeletal injury and diseases. Over the past decade, a large number of small molecules with the potential of regenerating skeletal tissue have been reported in the literature. Here, we review this literature, paying specific attention to the prospects for small molecule-based bone-regenerative engineering. We also review the preclinical study of small molecules associated with bone regeneration.

Primary prevention of cardiovascular events in patients with major mental illness: a possible role for statins

OBJECTIVES

To examine the need for and the possible benefits and risks of statin therapy in patients with major mental illness.

METHODS

Patients with psychiatric conditions, especially those with major mental illnesses such as schizophrenia and bipolar disorder, are at increased risk of overweight, obesity, dyslipidemia, diabetes mellitus, and the metabolic syndrome, all of which increase the risk of cardiovascular disease, cerebrovascular disease, and mortality. The literature on the subject was qualitatively reviewed.

RESULTS

Primary prevention benefits with statins are well known in the general population of high-risk patients; recent evidence suggests that statins also carry primary prevention benefits in low-risk subjects. Regrettably, the primary prevention of cardiovascular and cerebrovascular events in psychiatry is a neglected area in clinical practice as well as in interventional research, whether in high- or in low-risk patients. Initial concerns notwithstanding, psychiatric complications do not appear to be important among the adverse effects of statins. Although statins are associated with an increased risk of incident diabetes mellitus, myopathy, and other untoward consequences, the risk-benefit ratio appears to favor statin use. The advisability of using statins in low-risk or medically healthy subjects remains debatable.

CONCLUSIONS

Overweight, obesity, dyslipidemia, diabetes mellitus, and the metabolic syndrome are common in patients with major mental illness, and these increase the risk of medical morbidity and mortality. Statin use should therefore be considered for the primary prevention of cardiovascular and cerebrovascular events in psychiatric patients, especially in those at high risk.