Cyclic pamidronate therapy in children with osteogenesis imperfecta

Do Bisphosphonates Alleviate Pain in Children? A Systematic Review

PURPOSE OF REVIEW

The goal of this systematic review is to analyze the effectiveness of bisphosphonates (BPs) to treat bone pain in children and adolescents who have diseases with skeletal involvement.

RECENT FINDINGS

We included 24 studies (2 randomized controlled trials, 3 non-randomized controlled trials, 10 non-randomized open-label uncontrolled studies, 8 retrospective studies, and 1 study with design not specified). The majority of included studies assessed pain from a unidimensional approach, with pain intensity the most frequently evaluated dimension. Only 38% of studies used validated tools; visual analogue scale was the most frequently employed. BPs were used to alleviate bone pain in a wide variety of pediatrics conditions such as osteogenesis imperfecta, secondary osteoporosis, osteonecrosis related to chemotherapy, chronic non-bacterial osteitis, idiopathic juvenile osteoporosis, unresectable benign bone tumor, and cancer-related pain. Twenty of the 24 studies reported a positive effect of BPs for alleviating pain in different pathologies, but 58% of the studies were categorized as having high risk of bias. Intravenous BPs are helpful in alleviating bone pain in children and adolescents. It is advised that our results be interpreted with caution due to the heterogeneity of the doses used, duration of treatments, and types of pathologies included. In addition, this review shows the paucity of high-quality evidence in the available literature and further research is needed.

TRIAL REGISTRATION

Before the completion of this review, the protocol was registered to PROSPERO (International prospective register of systematic reviews), PROSPERO 2020 ID # CRD42020158316. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020158316.

Effect of Bisphosphonates on Function and Mobility Among Children With Osteogenesis Imperfecta: A Systematic Review

Osteogenesis imperfecta (OI) is a rare genetic connective tissue disorder that results in bone fragility and deformity. Management is multi-disciplinary. Although pharmacologic intervention with bisphosphonates (BP) is a standard of care for individuals with severe OI, no consensus or reviews were found that focus on the effects of bisphosphonates on function and mobility. PubMed, CINAHL, Cochrane Library, Web of Science, and PEDro databases were searched for eligible articles for this review. Methodological quality was assessed using the Cochrane Collaboration's tool for risk of bias. Twenty-six studies (801 children) were reviewed and five showed a low risk of bias. Included studies showed significant variability among clinical protocols for administering BP. Randomized controlled trials did not demonstrate a significant improvement in function and mobility with oral BP administration, while non-randomized open-label uncontrolled studies demonstrated that oral and intravenous BP administration objectively improved function and mobility. The most common outcome measure used by the studies included in this review was the Bleck score. Effect sizes (d = 0.28 - 4.5) varied among studies. This systematic review also summarized the apparent confounding variables affecting results of previous studies and provided suggestions to improve the quality of future studies.

Low Dose of Bisphosphonate Enhances Sclerostin Antibody-Induced Trabecular Bone Mass Gains in Brtl/+ Osteogenesis Imperfecta Mouse Model

Osteogenesis imperfecta (OI) is a genetic disorder characterized by altered bone quality and imbalanced bone remodeling, leading to skeletal fractures that are most prominent during childhood. Treatments for OI have focused on restoring pediatric bone density and architecture to recover functional strength and consequently reduce fragility. Though antiresorptive agents like bisphosphonates (BPs) are currently the most common intervention for the treatment of OI, a number of studies have shown efficacy of sclerostin antibody (SclAb) in inducing gains in bone mass and reducing fragility in OI mouse models. In this study, the effects of the concurrent use of BP and SclAb were evaluated during bone growth in a mouse harboring an OI-causing Gly→Cys mutation on col1a1. A single dose of antiresorptive BP facilitated the anabolic action of SclAb by increasing availability of surfaces for new bone formation via retention of primary trabeculae that would otherwise be remodeled. Chronic effects of concurrent administration of BP and SclAb revealed that accumulating cycles conferred synergistic gains in trabecular mass and vertebral stiffness, suggesting a distinct advantage of both therapies combined. Cortical gains in mass and strength occurred through SclAb alone, independent of presence of BP. In conclusion, these preclinical results support the scientific hypothesis that minimal antiresorptive treatment can amplify the effects of SclAb during early stages of skeletal growth to further improve bone structure and rigidity, a beneficial outcome for children with OI. © 2018 American Society for Bone and Mineral Research.

Fatigue and disturbances of sleep in patients with osteogenesis imperfecta - a cross-sectional questionnaire study

Background

Persisting fatigue has been reported to be a common complaint by individuals with connective tissue disorders, including Osteogenesis imperfecta (OI). This controlled study evaluated in an adult OI population the subjective experience of fatigue, affecting daily life. Sleep disturbances and chronic pain were examined as hypothesized underlying factors.

Methods

This cross-sectional study analyzed the answers of 56 OI patients and 56 matched healthy controls to a questionnaire, designed to evaluate levels of experienced fatigue and bodily pain, as well as the presence or absence of symptoms related to sleep disturbances or sleep apnea. The relationships between fatigue, pain, and sleep disturbances were evaluated with correlation analysis and regression analysis.

Results

Fatigue was reported by 96%, and daily pain by 87% of the individuals with OI. Notably, the level of fatigue was similarly experienced by patient respondents and controls. In total, 95% of the patients and 77% of the controls reported one to several sleep disturbance symptoms. These symptoms as well as previously diagnosed sleep apnea were statistically significantly more prevalent in the patient group than in the controls (p < 0.05). Likewise, the experienced bodily pain was statistically highly significantly more severe among the respondents with OI (p < 0.001), and correlated with the reported fatigue.

Conclusions

In comparison with age-matched controls, adults with OI do not differ in experienced fatigue, unlike hypothesized. Therefore, sleep disturbances, which based on the frequency of reported related symptoms and previous sleep apnea diagnoses appear to be common in OI patients, may remain undiagnosed.

Electronic supplementary material

The online version of this article (10.1186/s12891-017-1922-5) contains supplementary material, which is available to authorized users.

Establishment of age- and gender-specific pediatric reference intervals for liver function tests in healthy Han children

BACKGROUND

The development and growth of children influence values of liver function tests. This study aims to establish age- and gender-specific pediatric reference intervals of liver function among Han children in Changchun, China.

METHODS

A total of 1394 healthy Han children, aged 2-14 years, were recruited from communities and schools with informed parental consent in Changchun. The levels of serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), γ-glutamyltransferase (GGT), alkaline phosphatase (ALP), total protein (TP), albumin (ALB), total bilirubin (TBIL) and direct bilirubin (DBIL) were measured on Hitachi 7600-210 automatic biochemical analyzer. The age- and gender-specific reference intervals were partitioned using Harris and Boyd's test and calculated using nonparametric rank method. The pediatric reference intervals were validated in five representative hospitals located in different areas in Changchun.

RESULTS

All the analytes required some levels of age partitioning. Proteins (TP, ALB) and bilirubins (TBIL, DBIL) required no gender partitioning. In contrast, considerable gender partitioning was required for serum ALT, AST, GGT, and ALP. TP, TBIL, and DBIL showed steady increases, and AST showed apparent decreases over time, whereas ALT, GGT, ALP, and ALB demonstrated complex trends of change. ALT and GGT increased sharply in males from 11 to 14 years old. However, ALP declined in females from 13 to 14 years. All five laboratories passed the validation of reference intervals.

CONCLUSIONS

There were apparent age or gender variations of the reference intervals for liver function. When establishing pediatric reference intervals, partitioning according to age and gender is necessary.

Zoledronic acid in children with osteogenesis imperfecta and Bruck syndrome: a 2-year prospective observational study

Treatment with zoledronic acid (ZA) over 2 years, among 33 children with osteogenesis imperfecta (OI) and five Bruck syndrome cases, showed reduction in fracture rates, pain, and improvement in bone mineral density (BMD) and motor milestones of development. This is the first study reporting the use of bisphosphonates in patients with Bruck syndrome (BS).

INTRODUCTION

OI and BS are genetic disorders that result in bone fragility and reduced BMD. There is little literature describing the efficacy and safety of ZA in this population. In this study, we assess the response to treatment with ZA at six monthly intervals in Egyptian children with OI and BS for a period of 2 years.

METHODS

Thirty-three patients with OI and five patients with BS were treated with 0.1 mg/kg ZA intravenously every 6 months for 2 years during which they were followed up using different parameters. A clinical severity score (CSS) was applied to the patients before and 2 years after the start of therapy. Comparison of disease severity and response to ZA treatment between autosomal-dominant (AD) and autosomal-recessive (AR) OI patients was also done.

RESULTS

After 6 months of treatment, OI and BS patients showed a significant increase in BMD Z-scores (P < 0.003 in the spine and P < 0.004 in the hip), together with a significant drop in fracture rate (P < 0.001), relief of pain (P < 0.001), and improvement in ambulation (P < 0.001). CSS was significantly reduced after 2 years of treatment in both OI and BS patients. AR-OI patients were more severely affected than AD-OI patients and showed more significant improvement.

CONCLUSION

Zoledronic acid proved to be safe and effective in the treatment of OI and BS. The biannual infusion protocol was convenient to patients. There was a positive correlation between disease severity and benefits of the treatment. The use of the CSS proved to be of value in the assessment of the degree of severity in OI, and with some modifications, it was a valuable tool for the assessment of response to treatment.

Medication Repurposing in Pediatric Patients: Teaching Old Drugs New Tricks

OBJECTIVES

Gaps in pediatric therapeutics often result in off-label use and specifically, novel uses for existing medications, termed "drug repurposing." Drug Information (DI) queries to a Pediatric Medication Resource Center of a large metropolitan pediatric hospital in New York and inherent difficulties in retrieving evidence-based information prompted a review of current medication repurposing for pediatric patients. The objective included characterization of innovative off-label use of medications Food and Drug Administration (FDA)-approved for 1 or more indications to treat a totally different disorder or indication in pediatric patients.

METHODS

A systematic literature review was conducted to retrieve publications describing repurposed medications in pediatric patients. Excluded was FDA-approved indications used off-label in pediatric patients (e.g., different dose), preclinical data, adult use only, and experimental use. Evidence quality was classified using a modified American Academy of Neurology Level of Evidence. Results were analyzed using χ(2) at p < 0.05.

RESULTS

Over 2000 references were retrieved and reviewed. A total of 101 medications repurposed for novel off-label uses for pediatric patients were identified: 38 for neonates, 74 for children, and 52 for adolescents. Neonates and infants were least likely to receive a medication for a repurposed use. Strong or intermediate evidence existed in 80.2% of cases. The evidence was weak in 19.8%. No significant relationship was observed between the pediatric age group and strength of the literature. Most repurposed uses pertained to generic or widely used medications. Less than 5% of medications were first marketed after 2011.

CONCLUSIONS

While not exhaustive, the present study represents the most comprehensive listing of novel uses exclusive to pediatric patients. Further research is needed to identify the frequency of repurposed uses. The valuable DI role of pharmacists in assessing repurposed uses is of expanding and increasing importance to ensure such uses are evidence-based.

Weight loss surgery improves quality of life in pediatric patients with osteogenesis imperfecta

BACKGROUND

Osteogenesis imperfecta (OI) is an inherited disorder, which causes brittle bones resulting in recurrent fractures. The associated poor mobility of children with OI increases susceptibility to obesity, and obesity further dramatically limits mobility and increases fracture risk.

OBJECTIVES

The aim of this report is to describe outcomes of weight loss surgery (WLS) in 2 adolescents with severe obesity and OI.

SETTING

Two University Hospitals (in the United Kingdom and in the United States).

METHODS

Two cases of OI treated with WLS were identified. Pre- and postoperative anthropometric and biochemical data and clinical course were reviewed.

RESULTS

In these 2 cases, preoperative Body Mass Index (BMI) values were 38 and 46 kg/m². Following laparoscopic sleeve gastrectomy (LSG), BMI decreased by 55% and 60% by 26 and 24 months, respectively. There were no surgical complications, and both patients experienced improvement in their mobility and ability to perform activities of daily living.

CONCLUSION

WLS effectively treated severe obesity in 2 OI patients and substantially improved mobility and quality of life, theoretically reducing fracture risk.

Pharmacological interventions for pain in children and adolescents with life-limiting conditions

BACKGROUND

Pain is one of the most common symptoms in children and young people (CYP) with life-limiting conditions (LLCs) which include a wide range of diagnoses including cancer. The current literature indicates that pain is not well managed, however the evidence base to guide clinicians is limited. There is a clear need for evidence from a systematic review to inform prescribing.

OBJECTIVES

To evaluate the evidence on the effectiveness of different pharmacological interventions used for pain in CYP with LLCs.

SEARCH METHODS

The following electronic databases were searched up to December 2014: CENTRAL (in the Cochrane Library), MEDLINE, EMBASE, PsycINFO and CINAHL. In addition, we searched conference proceedings and reference lists of included studies. For completeness, we also contacted experts in the field. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-randomised studies and other studies that included a clearly defined comparator group were included. The studies investigated pharmacological treatments for pain associated with LLCs in CYP. The treatment included those specifically developed to treat pain and those that acted as an adjuvant, where the treatment was not primarily developed to treat pain but has pain relieving properties. The LLC was identified by its inclusion in the Richard Hain Directory of LLCs.

DATA COLLECTION AND ANALYSIS

Citations were screened by five review authors. Data were extracted by one review author and checked by a second. Two review authors assessed the risk of bias of included studies. A sufficient number of studies using homogeneous outcomes was not identified so a meta-analysis was not possible.

MAIN RESULTS

We identified 24,704 citations from our database search. Nine trials with 379 participants fulfilled our inclusion criteria. Participants had cerebral palsy (CP) in five of the studies and osteogenesis imperfecta (OI) in the other four. Participants across the trials ranged in age from 2 to 19 years. All studies, apart from one cross-over trial, were parallel designed RCTs. Three of the trials on CP evaluated intrathecal baclofen (ITB) and two botulinum toxin A (BoNT-A). All of the OI trials evaluated the use of bisphosphonates (two alendronate and one pamidronate). No trials were identified that evaluated a commonly used analgesic in this patient group. Pain was a secondary outcome in five of the eight identified studies. Overall the quality of the trials was mixed. Only one study involved over 100 participants.For the two ITB studies for pain in CP, in the same study population but assessed at different time points in their disease, both found an effect on pain favouring the intervention compared to the control group (standard care or placebo) (mean difference (MD) 4.20, 95% confidence interval (CI) 2.15 to 6.25; MD 26.60, 95% CI 2.61 to 50.59, respectively). In these studies most of the adverse events related to the procedure or device for administration rather than the drug, such as swelling at the pump site. In one trial there were also eight serious adverse effects; these included difficulty swallowing and an epileptic seizure. The trial did not state if these occurred in the intervention group. At follow-up in both BoNT-A trials there was no evidence of a difference in pain between the trial arms among CP participants. The adverse events in the BoNT-A trials mostly involved those who received the intervention drug and involved seizures. Gastrointestinal problems were the most frequent adverse event in those who received alendronate. The trial investigating pamidronate found no evidence of a difference in pain compared to the control group. No adverse events were reported in this trial.

AUTHORS' CONCLUSIONS

Published, controlled evidence on the pharmacological interventions for pain in CYP with LLCs is limited. The evidence that is currently available evaluated pain largely as a secondary outcome and the drugs used were all adjuvants and not always commonly used in general paediatric palliative care for pain. Based on current data this systematic review is unable to determine the effects of pharmacological interventions for pain for CYP with LLCs. Future trials with larger populations should examine the effects of the drugs commonly used as analgesics; with the rising prevalence of many LLCs this becomes more necessary.

[Osteogenesis imperfecta]

BACKGROUND

Osteogenesis imperfecta (OI) is the most common genetic disease of bone and is characterized by fragile bones and growth disorders of varying severity. Most cases of OI are inherited autosomal dominant and caused by a mutation in the collagen type I gene.

DIAGNOSTICS

Indications for OI are bone fragility, stunted growth, scoliosis, skull deformities, blue sclera, loss of hearing, dentinogenesis imperfecta and increased laxity of ligaments and skin. In most cases it is possible to make a clinical diagnosis but a skin biopsy or genetic testing can be useful; however, negative results for these tests do not exclude OI.

THERAPY

Therapy must be carried out in a multidisciplinary team and includes conservative (e.g. physiotherapy, rehabilitation programs and orthopedic aids), operative (e.g. intramedullary stabilization procedures) and pharmaceutical (e.g. biphosphonates and growth hormones) procedures.

PROGNOSIS

The prognosis depends on the type of OI and ranges from normal life expectations for type 1 patients up to up to perinatal mortality for type II patients.

A survey of steroid-related osteoporosis diagnosis, prevention and treatment practices of pediatric rheumatologists in North America

BACKGROUND

The purpose of our study is to assess practices of North American pediatric rheumatologists regarding monitoring, prevention, and treatment of low bone mineral density (BMD) in children on long-term glucocorticoid treatment. Long-term glucocorticoid therapy is associated with accelerated bone loss. Children with JIA and lupus have low baseline BMD and incident vertebral fractures commonly occur in these groups of patients even after a relatively short period of time being on systemic glucocorticoids. There are no established guidelines for identification, prevention, and treatment of glucocorticoid-induced bone loss in children.

METHODS

A cross-sectional online survey was conducted with 199 physicians who were listed in the ACR database as practicing pediatric rheumatology in North America.

RESULTS

86 physicians (43%) responded; 87% were board-certified in pediatric rheumatology. 95% used dual energy X-ray absorptiometry as their primary modality for assessing BMD. 79% "rarely" or "never" obtained a baseline BMD measurement prior to initiation of glucocorticoid therapy. 42% of respondents followed BMD annually. 93% "frequently" or "always" prescribed calcium for patients on long-term corticosteroid therapy; 81% "frequently" or "always" prescribed vitamin D. In patients diagnosed with osteoporosis, 35%-50 % of the practitioners "sometimes", "frequently" or "always" prescribed bisphosphonates. Bisphosphonates are prescribed at similar rates for male and female patients, and slightly more frequently for pubertal than for pre-pubertal patients. 96% of respondents "rarely" or "never" prescribed calcitonin for patients on long-term glucocorticoid therapy; 92% "rarely" or "never" prescribe this medication for patients with known osteopenia or osteoporosis.

CONCLUSIONS

Utilization of DXA in children on long-term corticosteroid therapy varies greatly among North American pediatric rheumatologists. Most respondents do not screen for low BMD on a regular basis despite acknowledging the risks of bone loss in this population. Broad consensus appears to be present among practitioners favoring the prescription of calcium and vitamin D for patients receiving long-term corticosteroid therapy. Relatively few respondents consistently recommend bisphosphonate therapy, even for patients with known low bone density; calcitonin is rarely used. These data underscore the need for studies to acquire specific data on bone loss, and its prevention and treatment in young patients on long-term glucocorticoid therapy.

Living donor liver transplantation for an infant with osteogenesis imperfecta and intrahepatic cholestasis: report of a case

Osteogenesis imperfecta (OI) is a group of genetic disorders characterized by bone fragility and connective tissue manifestations. We report a successful liver transplantation (LT) in an 8-month-old boy with OI and cholestatic biliary cirrhosis. After 4 cycles of intravenous pamidronate, LT was performed under intravenous anesthesia using a left lateral section from his mother without mechanical retractors. The operation time was 420 min and estimated blood loss was 520 mL requiring one unit of RBC transfusion. He was discharged without surgical complications. Therefore, LT should be considered for patients with end stage liver disease and OI under organic multidisciplinary cooperation.

Musculoskeletal functional outcomes in children with osteogenesis imperfecta: associations with disease severity and pamidronate therapy

BACKGROUND

Intravenous pamidronate has been used off-label in the treatment of severe osteogenesis imperfecta (OI) for almost 20 years. Previous studies have found correlations between function and bone density in patients with OI, but have not studied the functional outcomes of these patients after bisphosphonate therapy with a validated outcome measure. The goal of this investigation is to describe the functionality and comfort of children with OI. We hypothesize that function is impaired in children with severe OI as measured using the Pediatric Outcomes Data Collection Instrument (PODCI) and that improvements in the function of children with severe OI may be observed in association with intravenous bisphosphonate therapy.

METHODS

A total of 25 patients with OI were evaluated, of those, 15 received pamidronate therapy. Children with >2 long bone fractures per year were classified as having severe OI and were eligible for pamidronate therapy. Functional evaluation was performed using the PODCI for children who qualified for pamidronate therapy (severe OI) and those who did not qualify for pamidronate therapy (mild OI). PODCI evaluation was also performed after treatment with pamidronate in the group that qualified for pamidronate therapy.

RESULTS

There was a statistically significant difference at baseline between patients with "mild" and "severe" OI in the sports/physical functioning scale (P=0.0032). Among the children who received bisphosphonate therapy, PODCI scores in the sports/physical functioning domain were significantly improved after pamidronate therapy (P=0.0364).

CONCLUSIONS

This study indicates that children with mild forms of OI can be differentiated from their more severe counterparts by their ability to participate in high-level play activities. Furthermore, patients with "severe" OI show a significant improvement in their ability to participate in high-level play after 1 year of pamidronate.

LEVEL OF EVIDENCE

Level IV.

Radiographic features of osteogenesis imperfecta

Background

Osteogenesis imperfecta (OI), commonly called “brittle bone disease”, is a genetic disorder characterised by increased bone fragility and decreased bone density due to quantitative and/or qualitative abnormalities of type I collagen. Different types of OI exist, from mild to severe; they may lead to death, multiple bone fractures, skeletal deformity and short stature.

Methods

Severe cases are usually diagnosed before birth and may incite the parents to choose therapeutic abortion, whereas milder cases are much more difficult to diagnose and may be sometimes confused with non-accidental injury (NAI) (“child abuse”) in young children. Whatever the degree of severity, conventional radiography still remains the mainstay in diagnosing OI.

Results

The prognosis of this disorder has changed in the last few years thanks to biphosphonate therapy.

Conclusion

The aim of this pictorial review is to illustrate the radiographic manifestations of OI, including in children receiving biphosphonates, and to outline specific patterns that help differentiate OI from NAI when necessary.

Key Points

• The main radiographic features of OI are osteopenia, bone fractures and bone deformities.

• Some radiographic features depend on the type of OI or may be encountered with biphosphonates.

Surgical management of long bone pseudarthrosis with severe limb length discrepancy in osteogenesis imperfecta

We report a three-stage approach in managing an 18-year-old boy with osteogenesis imperfecta who had pseudarthrosis of the left femur with 150° anterior angulation and 9.5 cm shortening. Severe long bone deformity and pseudarthrosis in osteogenesis imperfecta are difficult to manage because of the relative shortening of the surrounding soft tissue and bone fragility. Our staged approach included excision of the pseudarthrosis, gradual soft tissue lengthening by external fixator, and a modified Sofield-Millar operation, to achieve union, deformity, and limb length correction without compromising much of the bone length. The patient was able to walk with support within 3 months and independently at 1 year. In this report, the management of the nonunion in osteogenesis imperfecta is discussed, with a focus on its difficulties and the management principles.

Mesenchymal stem cells in osteoarticular pediatric diseases: an update

Cellular therapy has gained an increasing popularity in recent years. Mesenchymal stem cells (MSCs) have the potential to differentiate into bone, cartilage, or fat tissue. In recent studies, these cells have also shown healing capability by improving angiogenesis and preventing fibrosis, which could have a role in tissue repair and tissue regeneration. Preclinical and clinical orthopedic studies conducted in the adult population support the use of MSCs for bone-healing problems, early stages of osteonecrosis, and local bone defects. Only a few published studies support the use of MSCs in pediatric osteoarticular disorders, probably due to the unknown long-term results of cellular therapy. The purpose of this review is to explain the mechanism by which MSCs could exhibit a therapeutic role in pediatric osteoarticular disorders.

Osteopenia in children with cerebral palsy can be treated with oral alendronate

PURPOSE

Cerebral palsy is one of the most common reasons of osteopenia in childhood. Patients have a significantly decreased bone mineral density, and painful fractures with minor traumas are common. Biphosphonates in the treatment of childhood osteoporosis are increasingly being used. This study aimed to evaluate the efficacy of oral alendronate treatment in children with cerebral palsy.

METHODS

Twenty-six children (16 boys and 10 girls) aged 3 to 17 years who had quadriplegic cerebral palsy and osteopenia were included in the study. The patients received alendronate (1 mg/kg/week), calcium (600 mg/day), and vitamin D(3) (400 U/day) over a year. A complete blood count, kidney and liver functional tests, plasma calcium, phosphate and alkaline phosphatase levels, and lumbar vertebral bone mineral density were measured before and after treatment.

RESULTS

Compared with pretreatment values, bone mineral density, serum calcium, and phosphate levels of the patients statistically increased and alkaline phosphatase levels decreased after treatment. No patient needed to interrupt treatment because of side effects.

CONCLUSIONS

Oral alendronate at a dose of 1 mg/kg/week for the treatment of osteopenia in children with cerebral palsy was found to be safe and effective.

Alendronate for the treatment of pediatric osteogenesis imperfecta: a randomized placebo-controlled study

CONTEXT

Information on the use of oral bisphosphonate agents to treat pediatric osteogenesis imperfecta (OI) is limited.

OBJECTIVE

The objective of the investigation was to study the efficacy and safety of daily oral alendronate (ALN) in children with OI.

DESIGN AND PARTICIPANTS

We conducted a multicenter, double-blind, randomized, placebo-controlled study. One hundred thirty-nine children (aged 4-19 yr) with type I, III, or IV OI were randomized to either placebo (n = 30) or ALN (n = 109) for 2 yr. ALN doses were 5 mg/d in children less than 40 kg and 10 mg/d for those 40 kg and greater.

MAIN OUTCOME MEASURES

Spine areal bone mineral density (BMD) z-score, urinary N-telopeptide of collagen type I, extremity fracture incidence, vertebral area, iliac cortical width, bone pain, physical activity, and safety parameters were measured.

RESULTS

ALN increased spine areal BMD by 51% vs. a 12% increase with placebo (P < 0.001); the mean spine areal BMD z-score increased significantly from -4.6 to -3.3 (P < 0.001) with ALN, whereas the change in the placebo group (from -4.6 to -4.5) was insignificant. Urinary N-telopeptide of collagen type I decreased by 62% in the ALN-treated group, compared with 32% with placebo (P < 0.001). Long-bone fracture incidence, average midline vertebral height, iliac cortical width, bone pain, and physical activity were similar between groups. The incidences of clinical and laboratory adverse experiences were also similar between the treatment and placebo groups.

CONCLUSIONS

Oral ALN for 2 yr in pediatric patients with OI significantly decreased bone turnover and increased spine areal BMD but was not associated with improved fracture outcomes.

Bisphosphonate use in conditions other than osteoporosis

Bisphosphonates are the gold standard of treatment of postmenopausal osteoporosis, male osteoporosis, and steroid-induced osteoporosis. They have potential use in multiple musculoskeletal conditions other than osteoporosis and have also been shown to treat Paget's disease of the bone and osteogenesis imperfecta. Bisphophonates may have potential use in periprosthetic bone loss, osteonecrosis of the hip, fibrous dysplasia, and calcinosis in juvenile dermatomyositis.