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Watts NB, Dore RK, Baim S, Mitlak B, Hattersley G, Wang Y, Rozental TD, LeBoff MS. Forearm bone mineral density and fracture incidence in postmenopausal women with osteoporosis: results from the ACTIVExtend phase 3 trial. Osteoporos Int 2021; 32:55-61. [PMID: 32935170 PMCID: PMC7755646 DOI: 10.1007/s00198-020-05555-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/17/2020] [Indexed: 11/17/2022]
Abstract
UNLABELLED Abaloparatide increased ultradistal radius bone mineral density (BMD) in the Abaloparatide Comparator Trial in Vertebral Endpoints (ACTIVE) trial. Over the subsequent 24 months in ACTIVExtend, ultradistal radius BMD gains were maintained with alendronate. Conversely, 1/3 radius BMD remained stable during ALN treatment in ACTIVExtend after decreasing during ACTIVE. INTRODUCTION Abaloparatide (ABL) increased femoral neck, total hip, and lumbar spine bone mineral density (BMD) in postmenopausal women with osteoporosis and decreased the risk of vertebral and nonvertebral fractures in ACTIVE. Effects on fracture risk and BMD were maintained subsequently with alendronate (ALN) in ACTIVExtend. In a prespecified subanalysis of ACTIVE, ABL also increased BMD at the ultradistal radius. Our objective was to determine the efficacy of ABL followed by ALN vs placebo (PBO) followed by ALN on forearm BMD and fracture risk over 43 months in ACTIVExtend. METHODS Ultradistal and 1/3 radius BMD (ACTIVE baseline to month 43) were measured (ABL/ALN, n = 213; PBO/ALN, n = 233). Wrist fracture rates were estimated for the ACTIVExtend intent-to-treat population (ABL/ALN, n = 558; PBO/ALN, n = 581) by Kaplan-Meier (KM) method. RESULTS At cumulative month 25, mean increase from ACTIVE baseline in ultradistal radius BMD was 1.1% (standard error, 0.49%) with ABL/ALN vs - 0.8% (0.43%) with PBO/ALN (P < 0.01). BMD increases with ABL were maintained with ALN through month 43 in ACTIVExtend. BMD decreases at the 1/3 radius in ACTIVE (similar with ABL and PBO) were maintained through 24 months of ALN treatment in ACTIVExtend. Wrist fractures over 43 months occurred in 15 women with ABL/ALN (KM estimate, 2.8%) and 20 with PBO/ALN (KM estimate, 3.6%) (HR = 0.77, 95% CI 0.39, 1.50; P = not significant). CONCLUSION Ultradistal radius BMD gains following treatment with ABL in ACTIVE were maintained over 24 months of ALN treatment in ACTIVExtend. Conversely, 1/3 radius BMD remained stable during ALN treatment in ACTIVExtend after decreasing during ACTIVE. TRIAL REGISTRATION ClinicalTrials.gov : NCT01657162 submitted July 31, 2012.
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Affiliation(s)
- N B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - R K Dore
- Robin K. Dore, MD, Inc., Tustin, CA, USA
| | - S Baim
- Rush University Medical Center, Chicago, IL, USA
| | - B Mitlak
- Radius Health, Inc., 950 Winter Street, Waltham, MA, 02451, USA.
| | - G Hattersley
- Radius Health, Inc., 950 Winter Street, Waltham, MA, 02451, USA
| | - Y Wang
- Radius Health, Inc., 950 Winter Street, Waltham, MA, 02451, USA
| | - T D Rozental
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - M S LeBoff
- Brigham and Women's Hospital, Boston, MA, USA
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Watts NB, Hattersley G, Fitzpatrick LA, Wang Y, Williams GC, Miller PD, Cosman F. Correction to: Abaloparatide effect on forearm bone mineral density and wrist fracture risk in postmenopausal women with osteoporosis. Osteoporos Int 2020; 31:1603-1605. [PMID: 32533195 PMCID: PMC7360655 DOI: 10.1007/s00198-020-05469-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The original version of this article, published on 21 March 2019, unfortunately contains some typos in Figs. 2, 3, 4, and Supplemental Fig. 1. The corrected figures are given below.
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Affiliation(s)
- N B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA.
| | | | | | - Y Wang
- Radius Health, Inc., Waltham, MA, USA
| | | | - P D Miller
- Colorado Center for Bone Research, Lakewood, CO, USA
| | - F Cosman
- Columbia University College of Physicians and Surgeons, New York, NY, USA
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Adami G, Saag KG, Mudano AS, Rahn EJ, Wright NC, Outman RC, Greenspan SL, LaCroix AZ, Nieves JW, Silverman SL, Siris ES, Watts NB, Miller MJ, Ladores S, Curtis JR, Danila MI. Factors associated with the contemplative stage of readiness to initiate osteoporosis treatment. Osteoporos Int 2020; 31:1283-1290. [PMID: 32020264 PMCID: PMC7365553 DOI: 10.1007/s00198-020-05312-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/22/2020] [Indexed: 02/02/2023]
Abstract
UNLABELLED We investigated the factors associated with readiness for initiating osteoporosis treatment in women at high risk of fracture. We found that women in the contemplative stage were more likely to report previously being told having osteoporosis or osteopenia, acknowledge concern about osteoporosis, and disclose prior osteoporosis treatment. INTRODUCTION Understanding factors associated with reaching the contemplative stage of readiness to initiate osteoporosis treatment may inform the design of behavioral interventions to improve osteoporosis treatment uptake in women at high risk for fracture. METHODS We measured readiness to initiate osteoporosis treatment using a modified form of the Weinstein Precaution Adoption Process Model (PAPM) among 2684 women at high risk of fracture from the Activating Patients at Risk for OsteoPOroSis (APROPOS) clinical trial. Pre-contemplative participants were those who self-classified in the unaware and unengaged stages of PAPM (stages 1 and 2). Contemplative participants were those in the undecided, decided not to act, or decided to act stages of PAPM (stages 3, 4, and 5). Using multivariable logistic regression, we evaluated participant characteristics associated with levels of readiness to initiate osteoporosis treatment. RESULTS Overall, 24% (N = 412) self-classified in the contemplative stage of readiness to initiate osteoporosis treatment. After adjusting for age, race, education, health literacy, and major osteoporotic fracture in the past 12 months, contemplative women were more likely to report previously being told they had osteoporosis or osteopenia (adjusted odds ratio [aOR] (95% CI) 11.8 (7.8-17.9) and 3.8 (2.5-5.6), respectively), acknowledge concern about osteoporosis (aOR 3.5 (2.5-4.9)), and disclose prior osteoporosis treatment (aOR 4.5 (3.3-6.3)) than women who self-classified as pre-contemplative. CONCLUSIONS For women at high risk for future fractures, ensuring women's recognition of their diagnosis of osteoporosis/osteopenia and addressing their concerns about osteoporosis are critical components to consider when attempting to influence stage of behavior transitions in osteoporosis treatment.
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Affiliation(s)
- G Adami
- University of Alabama at Birmingham, Birmingham, AL, 35233, USA
- Rheumatology Unit, University of Verona, Verona, Italy
| | - K G Saag
- University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - A S Mudano
- University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - E J Rahn
- University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - N C Wright
- University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - R C Outman
- University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - S L Greenspan
- University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - A Z LaCroix
- Group Health Cooperative, Seattle, WA, 98112, USA
- University of California San Diego, La Jolla, CA, 92093, USA
| | - J W Nieves
- Helen Hayes Hospital, West Haverstraw, NY, 10993, USA
| | - S L Silverman
- Cedars-Sinai Medical Center, Los Angeles, CA, 30211, USA
| | - E S Siris
- Columbia University Medical Center, New York, NY, 10032, USA
| | - N B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, 45236, USA
| | - M J Miller
- Texas A&M University, College Station, TX, 77843, USA
- Kaiser Permanente, Rockville, MD, 20852, USA
| | - S Ladores
- University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - J R Curtis
- University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - M I Danila
- University of Alabama at Birmingham, Birmingham, AL, 35233, USA.
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Watts NB, Hattersley G, Fitzpatrick LA, Wang Y, Williams GC, Miller PD, Cosman F. Correction to: Abaloparatide effect on forearm bone mineral density and wrist fracture risk in postmenopausal women with osteoporosis. Osteoporos Int 2020; 31:1017-1018. [PMID: 32232508 PMCID: PMC7170828 DOI: 10.1007/s00198-020-05349-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The original version of this article, published on 21 March 2019, unfortunately contained a mistake.
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Affiliation(s)
- N B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA.
| | | | | | - Y Wang
- Radius Health, Inc., Waltham, MA, USA
| | | | - P D Miller
- Colorado Center for Bone Research, Lakewood, CO, USA
| | - F Cosman
- Columbia University College of Physicians and Surgeons, New York, NY, USA
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Watts NB, Hattersley G, Fitzpatrick LA, Wang Y, Williams GC, Miller PD, Cosman F. Abaloparatide effect on forearm bone mineral density and wrist fracture risk in postmenopausal women with osteoporosis. Osteoporos Int 2019; 30:1187-1194. [PMID: 30899994 PMCID: PMC6546661 DOI: 10.1007/s00198-019-04890-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/31/2019] [Indexed: 10/31/2022]
Abstract
PURPOSE Wrist fractures are common, contribute significantly to morbidity in women with postmenopausal osteoporosis, and occur predominantly at the ultradistal radius, a site rich in trabecular bone. This exploratory analysis of the phase 3 ACTIVE study evaluated effects of abaloparatide versus placebo and teriparatide on forearm bone mineral density (BMD) and risk of wrist fracture. METHODS Forearm BMD was measured by dual energy X-ray absorptiometry in a subset of 982 women from ACTIVE, evenly distributed across the three treatment groups. Wrist fractures were ascertained in the total cohort (N = 2463). RESULTS After 18 months, ultradistal radius BMD changes from baseline were 2.25 percentage points greater for abaloparatide compared with placebo (95% confidence interval (CI) 1.38, 3.12, p < 0.001) and 1.54 percentage points greater for abaloparatide compared with teriparatide (95% CI 0.64, 2.45, p < 0.001). At 18 months, 1/3 radius BMD losses (versus baseline) were similar for abaloparatide compared with placebo (-0.42; 95% CI -1.03, 0.20; p = 0.19) but losses with teriparatide exceeded those of placebo (-1.66%; 95% CI -2.27, -1.06; p < 0.001). The decline with abaloparatide was less than that seen with teriparatide (group difference 1.22%; 95% CI 0.57, 1.87; p < 0.001). The radius BMD findings, at both ultradistal and 1/3 sites, are consistent with the numerically lower incidence of wrist fractures observed in women treated with abaloparatide compared with teriparatide (HR = 0.43; 95% CI 0.18, 1.03; p = 0.052) and placebo (HR = 0.49, 95% CI 0.20, 1.19, p = 0.11). CONCLUSIONS Compared with teriparatide, abaloparatide increased BMD at the ultradistal radius (primarily trabecular bone) and decreased BMD to a lesser extent at the 1/3 radius (primarily cortical bone), likely contributing to the numerically lower wrist fracture incidence observed with abaloparatide.
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Affiliation(s)
- N B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA.
| | | | | | - Y Wang
- Radius Health, Inc., Waltham, MA, USA
| | | | - P D Miller
- Colorado Center for Bone Research, Lakewood, CO, USA
| | - F Cosman
- Columbia University College of Physicians and Surgeons, New York, NY, USA
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Litwic AE, Compston JE, Wyman A, Siris ES, Gehlbach SH, Adachi JD, Chapurlat R, Díez-Pérez A, LaCroix AZ, Nieves JW, Netelenbos JC, Pfeilschifter J, Rossini M, Roux C, Saag KG, Silverman S, Watts NB, Greenspan SL, March L, Gregson CL, Cooper C, Dennison EM. Self-perception of fracture risk: what can it tell us? Osteoporos Int 2017; 28:3495-3500. [PMID: 28861636 PMCID: PMC5759929 DOI: 10.1007/s00198-017-4200-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 08/16/2017] [Indexed: 11/28/2022]
Abstract
UNLABELLED In this study, we report that self-perception of fracture risk captures some aspect of fracture risk not currently measured using conventional fracture prediction tools and is associated with improved medication uptake. It suggests that adequate appreciation of fracture risk may be beneficial and lead to greater healthcare engagement and treatment. INTRODUCTION This study aimed to assess how well self-perception of fracture risk, and fracture risk as estimated by the fracture prediction tool FRAX, related to fracture incidence and uptake and persistence of anti-osteoporosis medication among women participating in the Global Longitudinal study of Osteoporosis in Women (GLOW). METHODS GLOW is an international cohort study involving 723 physician practices across 10 countries in Europe, North America and Australia. Aged ≥ 55 years, 60,393 women completed baseline questionnaires detailing medical history, including co-morbidities, fractures and self-perceived fracture risk (SPR). Annual follow-up included self-reported incident fractures and anti-osteoporosis medication (AOM) use. We calculated FRAX risk without bone mineral density measurement. RESULTS Of the 39,241 women with at least 1 year of follow-up data, 2132 (5.4%) sustained an incident major osteoporotic fracture over 5 years of follow-up. Within each SPR category, risk of fracture increased as the FRAX categorisation of risk increased. In GLOW, only 11% of women with a lower baseline SPR were taking AOM at baseline, compared with 46% of women with a higher SPR. AOM use tended to increase in the years after a reported fracture. However, women with a lower SPR who were fractured still reported lower AOM rates than women with or without a fracture but had a higher SPR. CONCLUSIONS These results suggest that SPR captures some aspect of fracture risk not currently measured using conventional fracture prediction tools and is also associated with improved medication uptake.
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Affiliation(s)
- A E Litwic
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
| | | | - A Wyman
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - E S Siris
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - S H Gehlbach
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - J D Adachi
- St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - R Chapurlat
- INSERM U831, Division of Rheumatology, Hôpital E. Herriot, Université de Lyon, Lyon, France
| | - A Díez-Pérez
- Hospital del Mar-IMIM-Autonomous, University of Barcelona, Barcelona, Spain
| | - A Z LaCroix
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - J W Nieves
- Helen Hayes Hospital and Columbia University, West Haverstraw, NY, USA
| | - J C Netelenbos
- Department of Endocrinology, VU University Medical Center, Amsterdam, The Netherlands
| | - J Pfeilschifter
- Department of Internal Medicine III, Alfried Krupp Krankenhaus, Essen, Germany
| | - M Rossini
- Department of Rheumatology, University of Verona, Verona, Italy
| | - C Roux
- Cochin Hospital, Paris Descartes University, Paris, France
| | - K G Saag
- University of Alabama-Birmingham, Birmingham, AL, USA
| | - S Silverman
- Department of Rheumatology, Cedars-Sinai/UCLA, Los Angeles, CA, USA
| | - N B Watts
- Bone Health and Osteoporosis Center, University of Cincinnati, Cincinnati, OH, USA
| | | | - L March
- Faculty of Medicine and Department of Public Health, University of Sydney, Sydney, Australia
| | - C L Gregson
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
- Musculoskeletal Research Unit, Learning and Research Building, Southmead Hospital, University of Bristol, Bristol, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
- Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - E M Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK.
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Abstract
There is a growing list of medications used to treat non-skeletal disorders that cause bone loss and/or increase fracture risk. This review discusses glucocorticoids, drugs that reduce sex steroids, antidiabetic agents, acid-reducing drugs, selective serotonin reuptake inhibitors, and heparin. A number of drugs are known to cause bone loss, increase fracture risk, or both. These drugs should be used in the lowest dose necessary to achieve the desired benefit and for the shortest time necessary, but in many cases, long-term treatment is required. Effective countermeasures are available for some.
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Affiliation(s)
- N B Watts
- Mercy Health Osteoporosis and Bone Health Services, 4760 E. Galbraith Rd., Suite 212, Cincinnati, OH, 45236, USA.
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Masi L, Agnusdei D, Bilezikian J, Chappard D, Chapurlat R, Cianferotti L, Devolgelaer JP, El Maghraoui A, Ferrari S, Javaid K, Kaufman JM, Liberman UA, Lyritis G, Miller P, Napoli N, Roldan E, Papapoulos S, Watts NB, Brandi ML. Erratum to: Taxonomy of rare genetic metabolic bone disorders. Osteoporos Int 2015; 26:2717-8. [PMID: 26370825 DOI: 10.1007/s00198-015-3237-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- L Masi
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Florence, Italy
| | | | - J Bilezikian
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - D Chappard
- GEROM Groupe Etudes Remodelage Osseux et bioMatériaux-LHEA, IRIS-IBS Institut de Biologie en Santé, LUNAM Université, Angers, France
| | - R Chapurlat
- INSERM UMR 1033, Department of Rheumatology, Université de Lyon, Hospices Civils de Lyon, Lyon, France
| | - L Cianferotti
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Florence, Italy
| | - J-P Devolgelaer
- Departement de Medicine Interne, Cliniques Universitaires UCL de Saint Luc, Brussels, Belgium
| | - A El Maghraoui
- Service de Rhumatologie, Hôpital Militaire Mohammed V, Rabbat, Morocco
| | - S Ferrari
- Division of Bone Diseases, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - K Javaid
- Oxford NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - J-M Kaufman
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - U A Liberman
- Department of Physiology and Pharmacology and the Felsenstein Medical Research Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - G Lyritis
- Laboratory for the Research of Musculoskeletal System, University of Athens, Athens, Greece
| | - P Miller
- Colorado Center for Bone Research, University of Colorado Health Sciences Center, Lakewood, CO, USA
| | - N Napoli
- Division of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Rome, Italy
| | - E Roldan
- Department of Clinical Pharmacology, Gador SA, Buenos Aires, Argentina
| | - S Papapoulos
- Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - N B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - M L Brandi
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Florence, Italy.
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Masi L, Agnusdei D, Bilezikian J, Chappard D, Chapurlat R, Cianferotti L, Devolgelaer JP, El Maghraoui A, Ferrari S, Javaid MK, Kaufman JM, Liberman UA, Lyritis G, Miller P, Napoli N, Roldan E, Papapoulos S, Watts NB, Brandi ML. Taxonomy of rare genetic metabolic bone disorders. Osteoporos Int 2015; 26:2529-58. [PMID: 26070300 DOI: 10.1007/s00198-015-3188-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 05/26/2015] [Indexed: 12/26/2022]
Abstract
UNLABELLED This article reports a taxonomic classification of rare skeletal diseases based on metabolic phenotypes. It was prepared by The Skeletal Rare Diseases Working Group of the International Osteoporosis Foundation (IOF) and includes 116 OMIM phenotypes with 86 affected genes. INTRODUCTION Rare skeletal metabolic diseases comprise a group of diseases commonly associated with severe clinical consequences. In recent years, the description of the clinical phenotypes and radiographic features of several genetic bone disorders was paralleled by the discovery of key molecular pathways involved in the regulation of bone and mineral metabolism. Including this information in the description and classification of rare skeletal diseases may improve the recognition and management of affected patients. METHODS IOF recognized this need and formed a Skeletal Rare Diseases Working Group (SRD-WG) of basic and clinical scientists who developed a taxonomy of rare skeletal diseases based on their metabolic pathogenesis. RESULTS This taxonomy of rare genetic metabolic bone disorders (RGMBDs) comprises 116 OMIM phenotypes, with 86 affected genes related to bone and mineral homeostasis. The diseases were divided into four major groups, namely, disorders due to altered osteoclast, osteoblast, or osteocyte activity; disorders due to altered bone matrix proteins; disorders due to altered bone microenvironmental regulators; and disorders due to deranged calciotropic hormonal activity. CONCLUSIONS This article provides the first comprehensive taxonomy of rare metabolic skeletal diseases based on deranged metabolic activity. This classification will help in the development of common and shared diagnostic and therapeutic pathways for these patients and also in the creation of international registries of rare skeletal diseases, the first step for the development of genetic tests based on next generation sequencing and for performing large intervention trials to assess efficacy of orphan drugs.
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Affiliation(s)
- L Masi
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Florence, Italy
| | | | - J Bilezikian
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - D Chappard
- GEROM Groupe Etudes Remodelage Osseux et bioMatériaux-LHEA, IRIS-IBS Institut de Biologie en Santé, LUNAM Université, Angers, France
| | - R Chapurlat
- INSERM UMR 1033, Department of Rheumatology, Université de Lyon, Hospices Civils de Lyon, Lyon, France
| | - L Cianferotti
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Florence, Italy
| | - J-P Devolgelaer
- Departement de Medicine Interne, Cliniques Universitaires UCL de Saint Luc, Brussels, Belgium
| | - A El Maghraoui
- Service de Rhumatologie, Hôpital Militaire Mohammed V, Rabbat, Morocco
| | - S Ferrari
- Division of Bone Diseases, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - M K Javaid
- Oxford NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - J-M Kaufman
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - U A Liberman
- Department of Physiology and Pharmacology and the Felsenstein Medical Research Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - G Lyritis
- Laboratory for the Research of Musculoskeletal System, University of Athens, Athens, Greece
| | - P Miller
- Colorado Center for Bone Research, University of Colorado Health Sciences Center, Lakewood, CO, USA
| | - N Napoli
- Division of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Rome, Italy
| | - E Roldan
- Department of Clinical Pharmacology, Gador SA, Buenos Aires, Argentina
| | - S Papapoulos
- Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - N B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - M L Brandi
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University Hospital of Florence, University of Florence, Florence, Italy.
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Siris ES, Adler R, Bilezikian J, Bolognese M, Dawson-Hughes B, Favus MJ, Harris ST, Jan de Beur SM, Khosla S, Lane NE, Lindsay R, Nana AD, Orwoll ES, Saag K, Silverman S, Watts NB. The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group. Osteoporos Int 2014; 25:1439-43. [PMID: 24577348 PMCID: PMC3988515 DOI: 10.1007/s00198-014-2655-z] [Citation(s) in RCA: 368] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 02/11/2014] [Indexed: 12/13/2022]
Abstract
UNLABELLED Osteoporosis causes an elevated fracture risk. We propose the continued use of T-scores as one means for diagnosis but recommend that, alternatively, hip fracture; osteopenia-associated vertebral, proximal humerus, pelvis, or some wrist fractures; or FRAX scores with ≥3% (hip) or 20% (major) 10-year fracture risk also confer an osteoporosis diagnosis. INTRODUCTION Osteoporosis is a common disorder of reduced bone strength that predisposes to an increased risk for fractures in older individuals. In the USA, the standard criterion for the diagnosis of osteoporosis in postmenopausal women and older men is a T-score of ≤ -2.5 at the lumbar spine, femur neck, or total hip by bone mineral density testing. METHODS Under the direction of the National Bone Health Alliance, 17 clinicians and clinical scientists were appointed to a working group charged to determine the appropriate expansion of the criteria by which osteoporosis can be diagnosed. RESULTS The group recommends that postmenopausal women and men aged 50 years should be diagnosed with osteoporosis if they have a demonstrable elevated risk for future fractures. This includes having a T-score of less than or equal to -2.5 at the spine or hip as one method for diagnosis but also permits a diagnosis for individuals in this population who have experienced a hip fracture with or without bone mineral density (BMD) testing and for those who have osteopenia by BMD who sustain a vertebral, proximal humeral, pelvic, or, in some cases, distal forearm fracture. Finally, the term osteoporosis should be used to diagnose individuals with an elevated fracture risk based on the World Health Organization Fracture Risk Algorithm, FRAX. CONCLUSIONS As new ICD-10 codes become available, it is our hope that this new understanding of what osteoporosis represents will allow for an appropriate diagnosis when older individuals are recognized as being at an elevated risk for fracture.
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Affiliation(s)
- E S Siris
- Division of Endocrinology, Department of Medicine, Columbia University Medical Center, New York, NY, USA,
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11
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Gregson CL, Dennison EM, Compston JE, Adami S, Adachi JD, Anderson FA, Boonen S, Chapurlat R, Díez-Pérez A, Greenspan SL, Hooven FH, LaCroix AZ, Nieves JW, Netelenbos JC, Pfeilschifter J, Rossini M, Roux C, Saag KG, Silverman S, Siris ES, Watts NB, Wyman A, Cooper C. Disease-specific perception of fracture risk and incident fracture rates: GLOW cohort study. Osteoporos Int 2014; 25:85-95. [PMID: 23884437 PMCID: PMC3867337 DOI: 10.1007/s00198-013-2438-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 06/27/2013] [Indexed: 12/11/2022]
Abstract
UNLABELLED Accurate patient risk perception of adverse health events promotes greater autonomy over, and motivation towards, health-related lifestyles. INTRODUCTION We compared self-perceived fracture risk and 3-year incident fracture rates in postmenopausal women with a range of morbidities in the Global Longitudinal study of Osteoporosis in Women (GLOW). METHODS GLOW is an international cohort study involving 723 physician practices across ten countries (Europe, North America, Australasia); 60,393 women aged ≥55 years completed baseline questionnaires detailing medical history and self-perceived fracture risk. Annual follow-up determined self-reported incident fractures. RESULTS In total 2,945/43,832 (6.8%) sustained an incident fracture over 3 years. All morbidities were associated with increased fracture rates, particularly Parkinson's disease (hazard ratio [HR]; 95% confidence interval [CI], 3.89; 2.78-5.44), multiple sclerosis (2.70; 1.90-3.83), cerebrovascular events (2.02; 1.67-2.46), and rheumatoid arthritis (2.15; 1.53-3.04) (all p < 0.001). Most individuals perceived their fracture risk as similar to (46%) or lower than (36%) women of the same age. While increased self-perceived fracture risk was strongly associated with incident fracture rates, only 29% experiencing a fracture perceived their risk as increased. Under-appreciation of fracture risk occurred for all morbidities, including neurological disease, where women with low self-perceived fracture risk had a fracture HR 2.39 (CI 1.74-3.29) compared with women without morbidities. CONCLUSIONS Postmenopausal women with morbidities tend to under-appreciate their risk, including in the context of neurological diseases, where fracture rates were highest in this cohort. This has important implications for health education, particularly among women with Parkinson's disease, multiple sclerosis, or cerebrovascular disease.
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Affiliation(s)
- C L Gregson
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
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12
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Lindsay R, Watts NB, Lange JL, Delmas PD, Silverman SL. Effectiveness of risedronate and alendronate on nonvertebral fractures: an observational study through 2 years of therapy. Osteoporos Int 2013; 24:2345-52. [PMID: 23612793 DOI: 10.1007/s00198-013-2332-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 01/18/2013] [Indexed: 12/26/2022]
Abstract
UNLABELLED This observational study showed that after 2 years, both risedronate and alendronate lowered the risk of hip and nonvertebral fractures compared with patients filling in a single bisphosphonate prescription. INTRODUCTION Post hoc analyses of the placebo-controlled trials suggested earlier effects for risedronate (6-12 months) than for alendronate (18-24 months). The present study extends our 1-year observational data that confirmed an earlier fracture reduction with risedronate and evaluated the absolute and relative effectiveness of alendronate and risedronate in clinical practice over 2 years. METHODS We observed three cohorts of women aged 65 years and older who initiated once-a-week dosing of bisphosphonate therapy; (1) patients adherent to alendronate (n = 21,615), (2) patients adherent to risedronate (n = 12,215), or (3) patients filling only a single bisphosphonate prescription (n = 5,390) as a referent population. Proportional hazard modeling compared the incidence of hip and nonvertebral fractures among the cohorts over 2 years after the initial prescription. RESULTS In this cohort, we previously showed at 12 months a significant reduction of hip and nonvertebral fractures with risedronate but not with alendronate. At the end of 2 years, the cumulative incidence of hip fractures in the referent cohort was 1.9 %, and incidence of nonvertebral fractures was 6.3 %. Relative to the referent, 6 months after initiating therapy and continuing through 2 years, both risedronate and alendronate cohorts had approximately a 45 % lower incidence of hip fractures and a 30 % lower incidence of nonvertebral fractures. CONCLUSION These observations suggest that both risedronate and alendronate are effective at reducing the risk of hip and nonvertebral fracture after 2 years of treatment and support the post hoc analyses of placebo-controlled trials indicating an earlier effect of risedronate.
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Affiliation(s)
- R Lindsay
- Helen Hayes Hospital, 51-55 Route 9W, West Haverstraw, NY 10993, USA.
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13
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Ioannidis G, Flahive J, Pickard L, Papaioannou A, Chapurlat RD, Saag KG, Silverman S, Anderson FA, Gehlbach SH, Hooven FH, Boonen S, Compston JE, Cooper C, Díez-Perez A, Greenspan SL, LaCroix AZ, Lindsay R, Netelenbos JC, Pfeilschifter J, Rossini M, Roux C, Sambrook PN, Siris ES, Watts NB, Adachi JD. Non-hip, non-spine fractures drive healthcare utilization following a fracture: the Global Longitudinal Study of Osteoporosis in Women (GLOW). Osteoporos Int 2013; 24:59-67. [PMID: 22525976 PMCID: PMC4878124 DOI: 10.1007/s00198-012-1968-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 02/29/2012] [Indexed: 10/28/2022]
Abstract
UNLABELLED We evaluated healthcare utilization associated with treating fracture types in >51,000 women aged ≥55 years. Over the course of 1 year, there were five times more non-hip, non-spine fractures than hip or spine fractures, resulting in twice as many days of hospitalization and rehabilitation/nursing home care for non-hip, non-spine fractures. INTRODUCTION The purpose of this study is to evaluate medical healthcare utilization associated with treating several types of fractures in women ≥55 years from various geographic regions. METHODS Information from the Global Longitudinal Study of Osteoporosis in Women (GLOW) was collected via self-administered patient questionnaires at baseline and year 1 (n = 51,491). Self-reported clinically recognized low-trauma fractures at year 1 were classified as incident spine, hip, wrist/hand, arm/shoulder, pelvis, rib, leg, and other fractures. Healthcare utilization data were self-reported and included whether the fracture was treated at a doctor's office/clinic or at a hospital. Patients were asked if they had undergone surgery or been treated at a rehabilitation center or nursing home. RESULTS During 1-year follow-up, there were 195 spine, 134 hip, and 1,654 non-hip, non-spine fractures. Clinical vertebral fractures resulted in 617 days of hospitalization and 512 days of rehabilitation/nursing home care; hip fractures accounted for 1,306 days of hospitalization and 1,650 days of rehabilitation/nursing home care. Non-hip, non-spine fractures resulted in 3,805 days in hospital and 5,186 days of rehabilitation/nursing home care. CONCLUSIONS While hip and vertebral fractures are well recognized for their associated increase in health resource utilization, non-hip, non-spine fractures, by virtue of their 5-fold greater number, require significantly more healthcare resources.
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Affiliation(s)
- G. Ioannidis
- St. Joseph’s Hospital, McMaster University, 501-25 Charlton Ave E, Hamilton, ON L8N 1Y2, Canada
| | - J. Flahive
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - L. Pickard
- St. Joseph’s Hospital, McMaster University, 501-25 Charlton Ave E, Hamilton, ON L8N 1Y2, Canada
| | - A. Papaioannou
- St. Joseph’s Hospital, McMaster University, 501-25 Charlton Ave E, Hamilton, ON L8N 1Y2, Canada
| | - R. D. Chapurlat
- Division of Rheumatology, INSERM UMR 1033, Université de Lyon, Hospices Civils de Lyon, Hôpital E Herriot, Lyon, France
| | - K. G. Saag
- University of Alabama-Birmingham, Birmingham, AL, USA
| | - S. Silverman
- Department of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - F. A. Anderson
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - S. H. Gehlbach
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - F. H. Hooven
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - S. Boonen
- Leuven University Center for Metabolic Bone Diseases, Division of Geriatric Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - J. E. Compston
- University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK
| | - C. Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - A. Díez-Perez
- Hospital del Mar-IMIM-Autonomous University of Barcelona, Barcelona; and RETICEF, ISCIII Madrid; Spain
| | | | - A. Z. LaCroix
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - R. Lindsay
- Regional Bone Center, Helen Hayes Hospital, West Haverstraw, NY, USA
| | - J. C. Netelenbos
- Department of Endocrinology, VU University Medical Center, Amsterdam, The Netherlands
| | - J. Pfeilschifter
- Department of Internal Medicine III, Alfried Krupp Krankenhaus, Essen, Germany
| | - M. Rossini
- Section of Rheumatology, Department of Medicine, University of Verona, Verona, Italy
| | - C. Roux
- Paris Descartes University, Cochin Hospital, Paris, France
| | - P. N. Sambrook
- University of Sydney-Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia
| | - E. S. Siris
- Columbia University Medical Center, New York, NY, USA
| | - N. B. Watts
- Bone Health and Osteoporosis Center, University of Cincinnati, Cincinnati, OH, USA
| | - J. D. Adachi
- St. Joseph’s Hospital, McMaster University, 501-25 Charlton Ave E, Hamilton, ON L8N 1Y2, Canada, Tel: (905) 529-1317, Fax: (905) 521-1297
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14
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Roux C, Wyman A, Hooven FH, Gehlbach SH, Adachi JD, Chapurlat RD, Compston JE, Cooper C, Díez-Pérez A, Greenspan SL, Lacroix AZ, Netelenbos JC, Pfeilschifter J, Rossini M, Saag KG, Sambrook PN, Silverman S, Siris ES, Watts NB, Boonen S. Burden of non-hip, non-vertebral fractures on quality of life in postmenopausal women: the Global Longitudinal study of Osteoporosis in Women (GLOW). Osteoporos Int 2012; 23:2863-71. [PMID: 22398855 PMCID: PMC4881739 DOI: 10.1007/s00198-012-1935-8] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 01/13/2012] [Indexed: 10/28/2022]
Abstract
UNLABELLED Among 50,461 postmenopausal women, 1,822 fractures occurred (57% minor non-hip, non-vertebral [NHNV], 26% major NHNV, 10% spine, 7% hip) over 1 year. Spine fractures had the greatest detrimental effect on EQ-5D, followed by major NHNV and hip fractures. Decreases in physical function and health status were greatest for spine or hip fractures. INTRODUCTION There is growing evidence that NHNV fractures result in substantial morbidity and healthcare costs. The aim of this prospective study was to assess the effect of these NHNV fractures on quality of life. METHODS We analyzed the 1-year incidences of hip, spine, major NHNV (pelvis/leg, shoulder/arm) and minor NHNV (wrist/hand, ankle/foot, rib/clavicle) fractures among women from the Global Longitudinal study of Osteoporosis in Women (GLOW). Health-related quality of life (HRQL) was analyzed using the EuroQol EQ-5D tool and the SF-36 health survey. RESULTS Among 50,461 women analyzed, there were 1,822 fractures (57% minor NHNV, 26% major NHNV, 10% spine, 7% hip) over 1 year. Spine fractures had the greatest detrimental effect on EQ-5D summary scores, followed by major NHNV and hip fractures. The number of women with mobility problems increased most for those with major NHNV and spine fractures (both +8%); spine fractures were associated with the largest increases in problems with self care (+11%), activities (+14%), and pain/discomfort (+12%). Decreases in physical function and health status were greatest for those with spine or hip fractures. Multivariable modeling found that EQ-5D reduction was greatest for spine fractures, followed by hip and major/minor NHNV. Statistically significant reductions in SF-36 physical function were found for spine fractures, and were borderline significant for major NHNV fractures. CONCLUSION This prospective study shows that NHNV fractures have a detrimental effect on HRQL. Efforts to optimize the care of osteoporosis patients should include the prevention of NHNV fractures.
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Affiliation(s)
- C Roux
- Department of Rheumatology, Cochin Hospital, Paris Descartes University, 27 rue du Faubourg St. Jacques, 75659, Paris Cedex 14, France.
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15
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Pfeilschifter J, Cooper C, Watts NB, Flahive J, Saag KG, Adachi JD, Boonen S, Chapurlat R, Compston JE, Díez-Pérez A, LaCroix AZ, Netelenbos JC, Rossini M, Roux C, Sambrook PN, Silverman S, Siris ES. Regional and age-related variations in the proportions of hip fractures and major fractures among postmenopausal women: the Global Longitudinal Study of Osteoporosis in Women. Osteoporos Int 2012; 23:2179-88. [PMID: 22086311 DOI: 10.1007/s00198-011-1840-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 11/02/2011] [Indexed: 11/28/2022]
Abstract
UNLABELLED We examined variations in proportions of hip fractures and major fractures among postmenopausal women using the Global Longitudinal Study of Osteoporosis in Women (GLOW). The proportion of major fractures that were hip fractures varied with age and region, whereas variations in the proportion of fractures that were major fractures appeared modest. INTRODUCTION In many countries, the World Health Organization fracture risk assessment tool calculates the probability of major fractures by assuming a uniform age-associated proportion of major fractures that are hip fractures in different countries. We further explored this assumption, using data from the GLOW. METHODS GLOW is an observational population-based study of 60,393 non-institutionalized women aged ≥55 years who had visited practices within the previous 2 years. Main outcome measures were self-reported prevalent fractures after the age of 45 years and incident fractures during the 2 years of follow-up. RESULTS The adjusted proportion of prevalent and incident major fractures after the age of 45 years that were hip fractures was higher in North America (16%, 17%) than in northern (13%, 12%) and southern Europe (10%, 10%), respectively. The proportion of incident major fractures that were hip fractures increased more than five-fold with age, from 6.6% among 55-59-year-olds to 34% among those aged ≥85 years. Regional and age-associated variations in the proportion of all incident fractures that were major fractures were less marked, not exceeding 16% and 28%, respectively. CONCLUSIONS The data suggest that there may be regional differences in the proportion of major fractures that are hip fractures in postmenopausal women. In contrast, the regional and age-related variations in the proportion of fractures that are major fractures appear to be modest. However, because of the limited number of fractures in our sample, further studies are necessary to confirm these findings.
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Affiliation(s)
- J Pfeilschifter
- Department of Internal Medicine III, Alfried Krupp Krankenhaus, Essen, Germany.
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16
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Watts NB, Roux C, Modlin JF, Brown JP, Daniels A, Jackson S, Smith S, Zack DJ, Zhou L, Grauer A, Ferrari S. Infections in postmenopausal women with osteoporosis treated with denosumab or placebo: coincidence or causal association? Osteoporos Int 2012; 23:327-37. [PMID: 21892677 PMCID: PMC3249159 DOI: 10.1007/s00198-011-1755-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 06/23/2011] [Indexed: 01/29/2023]
Abstract
UNLABELLED Serious adverse events of infections that occurred in subjects receiving denosumab or placebo in the Fracture Reduction Evaluation of Denosumab in Osteoporosis every 6 Months (FREEDOM) study were examined in detail. Serious adverse events of infections in denosumab subjects had heterogeneous etiology, with no clear clinical pattern to suggest a relationship to time or duration of exposure to denosumab. INTRODUCTION Denosumab reduces the risk for new vertebral, hip, and nonvertebral fractures compared with placebo. In the pivotal phase 3 fracture trial (FREEDOM), the overall safety profile and incidence of adverse events including adverse events of infections were similar between groups. Serious adverse events of erysipelas and cellulitis were more frequent in denosumab-treated subjects. In this report, we further evaluate the details of infectious events in FREEDOM to better understand if RANKL inhibition with denosumab influences infection risk. METHODS FREEDOM was an international multicenter, randomized, double-blind, placebo-controlled study in postmenopausal women with osteoporosis randomly assigned to receive placebo (n = 3,906) or denosumab 60 mg every 6 months (n = 3,902). The incidence of adverse events and serious adverse events categorized within the Medical Dictionary for Regulatory Activities system organ class, "Infections and Infestations," was compared between the placebo and denosumab groups by body systems and preferred terms. The temporal relationship between occurrence of serious adverse events of infections of interest and administration of denosumab was explored. RESULTS Serious adverse events of infections involving the gastrointestinal system, renal and urinary system, ear, and endocarditis were numerically higher in the denosumab group compared with placebo, but the number of events was small. No relationship was observed between serious adverse events of infections and timing of administration or duration of exposure to denosumab. CONCLUSIONS Serious adverse events of infections that occurred with denosumab treatment had heterogeneous etiology, with no clear clinical pattern to suggest a relationship to time or duration of exposure to denosumab.
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MESH Headings
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Bone Density Conservation Agents/administration & dosage
- Bone Density Conservation Agents/adverse effects
- Bone Density Conservation Agents/therapeutic use
- Denosumab
- Double-Blind Method
- Drug Administration Schedule
- Endocarditis/chemically induced
- Endocarditis/complications
- Female
- Gastrointestinal Diseases/chemically induced
- Gastrointestinal Diseases/complications
- Humans
- Middle Aged
- Opportunistic Infections/complications
- Opportunistic Infections/etiology
- Osteoporosis, Postmenopausal/complications
- Osteoporosis, Postmenopausal/drug therapy
- Osteoporotic Fractures/prevention & control
- Otitis/chemically induced
- Otitis/complications
- Placebos
- RANK Ligand/antagonists & inhibitors
- Skin Diseases, Infectious/chemically induced
- Skin Diseases, Infectious/complications
- Urinary Tract Infections/chemically induced
- Urinary Tract Infections/complications
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Affiliation(s)
- N B Watts
- Bone Health and Osteoporosis Center, College of Medicine, University of Cincinnati, 222 Piedmont Avenue, Suite 6300, Cincinnati, OH 45219, USA.
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17
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Siris ES, Gehlbach S, Adachi JD, Boonen S, Chapurlat RD, Compston JE, Cooper C, Delmas P, Díez-Pérez A, Hooven FH, Lacroix AZ, Netelenbos JC, Pfeilschifter J, Rossini M, Roux C, Saag KG, Sambrook P, Silverman S, Watts NB, Wyman A, Greenspan SL. Failure to perceive increased risk of fracture in women 55 years and older: the Global Longitudinal Study of Osteoporosis in Women (GLOW). Osteoporos Int 2011; 22:27-35. [PMID: 20358360 PMCID: PMC3017306 DOI: 10.1007/s00198-010-1211-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 02/02/2010] [Indexed: 11/28/2022]
Abstract
UNLABELLED We compared self-perception of fracture risk with actual risk among 60,393 postmenopausal women aged ≥55 years, using data from the Global Longitudinal Study of Osteoporosis in Women (GLOW). Most postmenopausal women with risk factors failed to appreciate their actual risk for fracture. Improved education about osteoporosis risk factors is needed. INTRODUCTION This study seeks to compare self-perception of fracture risk with actual risk among postmenopausal women using data from GLOW. METHODS GLOW is an international, observational, cohort study involving 723 physician practices in 17 sites in ten countries in Europe, North America, and Australia. Participants included 60,393 women ≥55 years attended by their physician during the previous 24 months. The sample was enriched so that two thirds were ≥65 years. Baseline surveys were mailed October 2006 to February 2008. Main outcome measures were self-perception of fracture risk in women with elevated risk vs women of the same age and frequency of risk factors for fragility fracture. RESULTS In the overall study population, 19% (10,951/58,434) of women rated their risk of fracture as a little/much higher than that of women of the same age; 46% (27,138/58,434) said it was similar; 35% (20,345/58,434) believed it to be a little/much lower. Among women whose actual risk was increased based on the presence of any one of seven risk factors for fracture, the proportion who recognized their increased risk ranged from 19% for smokers to 39% for current users of glucocorticoid medication. Only 33% (4,185/12,612) of those with ≥2 risk factors perceived themselves as being at higher risk. Among women reporting a diagnosis of osteopenia or osteoporosis, only 25% and 43%, respectively, thought their risk was increased. CONCLUSION In this international, observational study, most postmenopausal women with risk factors failed to appreciate their actual risk for fracture.
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Affiliation(s)
- E S Siris
- Department of Medicine, Columbia University Medical Center, 180 Fort Washington Avenue, Harkness Pavilion 9-964, New York, NY 10032, USA.
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18
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Blank RD, Bilezikian JP, Bonnick SL, Laster AJ, Leib ES, Lewiecki EM, Miller PD, Watts NB, Binkley N. "Evidence-based" or "logic-based" medicine? Osteoporos Int 2010; 21:1681-3. [PMID: 20464543 DOI: 10.1007/s00198-010-1269-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Accepted: 03/30/2010] [Indexed: 10/19/2022]
Abstract
Low trauma fractures are the cardinal manifestation of osteoporosis. Their occurrence supersedes bone mineral density in deciding whether specific therapy is warranted. We therefore disagree with the notion that a densitometric threshold for treatment should be applied to patients over age 50 who suffer low trauma distal radius fracture.
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Affiliation(s)
- R D Blank
- Geriatrics Research, Education, and Clinical Center, William S. Middleton Veterans Hospital, Madison, WI, USA.
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19
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Cooper C, Steinbuch M, Stevenson R, Miday R, Watts NB. The epidemiology of osteonecrosis: findings from the GPRD and THIN databases in the UK. Osteoporos Int 2010; 21:569-77. [PMID: 19547906 PMCID: PMC2832873 DOI: 10.1007/s00198-009-1003-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Accepted: 05/22/2009] [Indexed: 12/02/2022]
Abstract
UNLABELLED We conducted a case-control study to examine osteonecrosis (ON) incidence, patient characteristics, and selected potential risk factors using two health record databases in the UK. Statistically significant risk factors for ON included systemic corticosteroid use, hospitalization, referral or specialist visit, bone fracture, any cancer, osteoporosis, connective tissue disease, and osteoarthritis. INTRODUCTION The purpose of this case-control study was to examine the incidence of osteonecrosis (ON), patient characteristics, and selected potential risk factors for ON using two health record databases in the UK: the General Practice Research Database and The Health Improvement Network. METHODS ON cases (n = 792) were identified from 1989 to 2003 and individually matched (age, sex, and medical practice) up to six controls (n = 4,660) with no record of ON. Possible risk factors were considered for inclusion based on a review of published literature. Annual incidence rates were computed, and a multivariable logistic regression model was derived to evaluate selected risk factors. RESULTS ON of the hip represented the majority of cases (75.9%). Statistically significant risk factors for ON were systemic corticosteroid use in the previous 2 years, hospitalization, referral or specialist visit, bone fracture, any cancer, osteoporosis, connective tissue disease, and osteoarthritis within the past 5 years. Only 4.4% of ON cases were exposed to bisphosphonates within the previous 2 years. CONCLUSIONS This study provides further perspective on the descriptive epidemiology of ON. Studies utilizing more recent data may further elucidate the understanding of ON key predictors.
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Affiliation(s)
- C. Cooper
- Rheumatology, University of Southampton, Southampton, UK
- MRC Epidemiology Resource Centre, University of Southampton, Southampton, UK
- Institute of Musculoskeletal Science, University of Oxford, Oxford, UK
| | - M. Steinbuch
- Pharmacovigilance and Epidemiology, Procter & Gamble Company, Mason, OH 45040 USA
| | - R. Stevenson
- Pharmacovigilance and Epidemiology, Procter & Gamble Company, Mason, OH 45040 USA
| | - R. Miday
- Pharmacovigilance and Epidemiology, Procter & Gamble Company, Mason, OH 45040 USA
| | - N. B. Watts
- Bone Health and Osteoporosis Center, University of Cincinnati College of Medicine, Cincinnati, OH 45219 USA
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20
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Hooven FH, Adachi JD, Adami S, Boonen S, Compston J, Cooper C, Delmas P, Diez-Perez A, Gehlbach S, Greenspan SL, LaCroix A, Lindsay R, Netelenbos JC, Pfeilschifter J, Roux C, Saag KG, Sambrook P, Silverman S, Siris E, Watts NB, Anderson FA. The Global Longitudinal Study of Osteoporosis in Women (GLOW): rationale and study design. Osteoporos Int 2009; 20:1107-16. [PMID: 19468663 PMCID: PMC2690851 DOI: 10.1007/s00198-009-0958-2] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 04/21/2009] [Indexed: 11/06/2022]
Abstract
SUMMARY The Global Longitudinal study of Osteoporosis in Women (GLOW) is a prospective cohort study involving 723 physicians and 60,393 women subjects >or=55 years. The data will provide insights into the management of fracture risk in older women over 5 years, patient experience with prevention and treatment, and distribution of risk among older women on an international basis. INTRODUCTION Data from cohort studies describing the distribution of osteoporosis-related fractures and risk factors are not directly comparable and do not compare regional differences in patterns of patient management and fracture outcomes. METHODS The GLOW is a prospective, multinational, observational cohort study. Practices typical of each region were identified through primary care networks organized for administrative, research, or educational purposes. Noninstitutionalized patients visiting each practice within the previous 2 years were eligible. Self-administered questionnaires were mailed, with 2:1 oversampling of women >or=65 years. Follow-up questionnaires will be sent at 12-month intervals for 5 years. RESULTS A total of 723 physicians at 17 sites in ten countries agreed to participate. Baseline surveys were mailed (October 2006 to February 2008) to 140,416 subjects. After the exclusion of 3,265 women who were ineligible or had died, 60,393 agreed to participate. CONCLUSIONS GLOW will provide contemporary information on patterns of management of fracture risk in older women over a 5-year period. The collection of data in a similar manner in ten countries will permit comparisons of patient experience with prevention and treatment and provide insights into the distribution of risk among older women on an international basis.
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Affiliation(s)
- F H Hooven
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA 01605, USA.
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21
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Abstract
Patients treated with pharmacological agents to improve bone strength and reduce fracture risk may not achieve optimal skeletal benefit for reasons that include poor compliance and persistence, inadequate calcium and vitamin D intake, malabsorption, and medications or co-morbidities with adverse skeletal effects. Monitoring the effects of therapy can inform the patient and physician that the drug is having its expected skeletal response. Treatment is often monitored with serial bone mineral density (BMD) measurements using dual-energy X-ray absorptiometry or bone turnover markers (BTMs). Stable or increasing BMD is associated with reduced fracture risk in clinical trials, and is considered an indication of good response to therapy in individual patients outside of clinical trials. There are many differences between subjects in clinical trials and patients being treated in clinical practice. Thus, although defining a clinical practice patient as a "nonresponder" or "suboptimal responder" to treatment is problematic, a pragmatic approach would be to consider evaluation for contributing factors and possible changes in therapy in patients who have a statistically significant decrease in BMD, do not have the expected change in BTMs, or have a fracture.
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Affiliation(s)
- E M Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, 300 Oak St. NE, Albuquerque, NM 87106, USA.
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Russell RGG, Watts NB, Ebetino FH, Rogers MJ. Mechanisms of action of bisphosphonates: similarities and differences and their potential influence on clinical efficacy. Osteoporos Int 2008; 19:733-59. [PMID: 18214569 DOI: 10.1007/s00198-007-0540-8] [Citation(s) in RCA: 941] [Impact Index Per Article: 58.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Accepted: 11/27/2007] [Indexed: 12/12/2022]
Abstract
UNLABELLED Bisphosphonates (BPs) are well established as the leading drugs for the treatment of osteoporosis. There is new knowledge about how they work. The differences that exist among individual BPs in terms of mineral binding and biochemical actions may explain differences in their clinical behavior and effectiveness. INTRODUCTION The classical pharmacological effects of bisphosphonates (BPs) appear to be the result of two key properties: their affinity for bone mineral and their inhibitory effects on osteoclasts. DISCUSSION There is new information about both properties. Mineral binding affinities differ among the clinically used BPs and may influence their differential distribution within bone, their biological potency, and their duration of action. The antiresorptive effects of the nitrogen-containing BPs (including alendronate, risedronate, ibandronate, and zoledronate) appear to result from their inhibition of the enzyme farnesyl pyrophosphate synthase (FPPS) in osteoclasts. FPPS is a key enzyme in the mevalonate pathway, which generates isoprenoid lipids utilized for the post-translational modification of small GTP-binding proteins that are essential for osteoclast function. Effects on other cellular targets, such as osteocytes, may also be important. BPs share several common properties as a drug class. However, as with other families of drugs, there are obvious chemical, biochemical, and pharmacological differences among the individual BPs. Each BP has a unique profile that may help to explain potential clinical differences among them, in terms of their speed and duration of action, and effects on fracture reduction.
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Affiliation(s)
- R G G Russell
- Nuffield Department of Orthopaedic Surgery, Oxford University Institute of Musculoskeletal Sciences (The Botnar Research Centre), Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD, UK.
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Watts NB, Chines A, Olszynski WP, McKeever CD, McClung MR, Zhou X, Grauer A. Fracture risk remains reduced one year after discontinuation of risedronate. Osteoporos Int 2008; 19:365-72. [PMID: 17938986 DOI: 10.1007/s00198-007-0460-7] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Accepted: 07/31/2007] [Indexed: 11/24/2022]
Abstract
UNLABELLED One year after discontinuation of three year's treatment with risedronate, BMD decreased at the lumbar spine and femoral neck and bone turnover markers returned to control group levels. Despite these changes, the risk of new morphometric vertebral fractures remained lower in previous risedronate patients compared with previous control patients. INTRODUCTION Differences in bisphosphonate pharmacology and pharmacokinetics could influence persistence or resolution of the effects once treatment is stopped. We investigated changes in intermediate markers--bone mineral density (BMD) and bone turnover markers (BTM)--and fracture risk after discontinuation of treatment with risedronate. METHODS Patients who received risedronate 5 mg daily (N = 398) or placebo (N = 361) during the VERT-NA study stopped therapy per protocol after 3 years but continued taking vitamin D (if levels at study entry were low) and calcium and were reassessed one year later. RESULTS In the year off treatment, spine BMD decreased significantly, but remained higher than baseline (p < or = 0.001) and placebo (p < 0.001), with similar findings at the femoral neck and trochanter. Urinary NTX and bone-specific alkaline phosphatase, which decreased significantly with treatment, were not significantly different from placebo after 1 year off treatment. Despite the changes in intermediate markers, the incidence of new morphometric vertebral fractures was 46% lower in the former risedronate group compared with the former placebo group (RR 0.54 [95% CI, 0.34, 0.86, p = 0.009]). CONCLUSIONS Despite the apparent resolution of effect on BMD and BTM, the risk reduction of new vertebral fractures remained in the year after treatment with risedronate was stopped.
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Affiliation(s)
- N B Watts
- University of Cincinnati Bone Health and Osteoporosis Center, 222 Piedmont Avenue, Suite 4300, Cincinnati, OH 45219, USA.
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Kanis JA, Oden A, Johnell O, Johansson H, De Laet C, Brown J, Burckhardt P, Cooper C, Christiansen C, Cummings S, Eisman JA, Fujiwara S, Glüer C, Goltzman D, Hans D, Krieg MA, La Croix A, McCloskey E, Mellstrom D, Melton LJ, Pols H, Reeve J, Sanders K, Schott AM, Silman A, Torgerson D, van Staa T, Watts NB, Yoshimura N. The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int 2007; 18:1033-46. [PMID: 17323110 DOI: 10.1007/s00198-007-0343-y] [Citation(s) in RCA: 807] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2006] [Accepted: 01/19/2007] [Indexed: 02/07/2023]
Abstract
UNLABELLED BMD and clinical risk factors predict hip and other osteoporotic fractures. The combination of clinical risk factors and BMD provide higher specificity and sensitivity than either alone. INTRODUCTION AND HYPOTHESES: To develop a risk assessment tool based on clinical risk factors (CRFs) with and without BMD. METHODS Nine population-based studies were studied in which BMD and CRFs were documented at baseline. Poisson regression models were developed for hip fracture and other osteoporotic fractures, with and without hip BMD. Fracture risk was expressed as gradient of risk (GR, risk ratio/SD change in risk score). RESULTS CRFs alone predicted hip fracture with a GR of 2.1/SD at the age of 50 years and decreased with age. The use of BMD alone provided a higher GR (3.7/SD), and was improved further with the combined use of CRFs and BMD (4.2/SD). For other osteoporotic fractures, the GRs were lower than for hip fracture. The GR with CRFs alone was 1.4/SD at the age of 50 years, similar to that provided by BMD (GR = 1.4/SD) and was not markedly increased by the combination (GR = 1.4/SD). The performance characteristics of clinical risk factors with and without BMD were validated in eleven independent population-based cohorts. CONCLUSIONS The models developed provide the basis for the integrated use of validated clinical risk factors in men and women to aid in fracture risk prediction.
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Affiliation(s)
- J A Kanis
- WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
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Silverman SL, Watts NB, Delmas PD, Lange JL, Lindsay R. Effectiveness of bisphosphonates on nonvertebral and hip fractures in the first year of therapy: the risedronate and alendronate (REAL) cohort study. Osteoporos Int 2007; 18:25-34. [PMID: 17106785 PMCID: PMC1705543 DOI: 10.1007/s00198-006-0274-z] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Accepted: 10/17/2006] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Randomized clinical trials have shown that risedronate and alendronate reduce fractures among women with osteoporosis. The aim of this observational study was to observe, in clinical practice, the incidence of hip and nonvertebral fractures among women in the year following initiation of once-a-week dosing of either risedronate or alendronate. METHODS Using records of health service utilization from July 2002 through September 2004, we created two cohorts: women (ages 65 and over) receiving risedronate (n = 12,215) or alendronate (n = 21,615). Cox proportional hazard modeling was used to compare the annual incidence of nonvertebral fractures and of hip fractures between cohorts, adjusting for potential differences in risk factors for fractures. RESULTS There were 507 nonvertebral fractures and 109 hip fractures. Through one year of therapy, the incidence of nonvertebral fractures in the risedronate cohort (2.0%) was 18% lower (95% CI 2% - 32%) than in the alendronate cohort (2.3%). The incidence of hip fractures in the risedronate cohort (0.4%) was 43% lower (95% CI 13% - 63%) than in the alendronate cohort (0.6%). These results were consistent across a number of sensitivity analyses. CONCLUSION Patients receiving risedronate have lower rates of hip and nonvertebral fractures during their first year of therapy than patients receiving alendronate.
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Affiliation(s)
- S L Silverman
- Cedars-Sinai Medical Center and David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA 90211, USA.
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Hamdy R, Kiebzak GM, Seier E, Watts NB. The prevalence of significant left-right differences in hip bone mineral density. Osteoporos Int 2006; 17:1772-80. [PMID: 17019523 DOI: 10.1007/s00198-006-0192-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Accepted: 06/16/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION We determined the prevalence of left-right differences in hip bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) and the resultant consequence, namely: the frequency at which patients would be classified differently if lumbar spine and only one hip (rather than both hips) were measured. METHODS This was a retrospective DXA scan reanalysis of 3012 white women >or=50 yrs who had scans of both hips using Hologic DXA systems. The difference between left and right hips was considered significant if it exceeded the least significant change (LSC) for any of three hip subregions (total hip, femoral neck, trochanter). The number of women with osteoporosis in both hips, the left hip only, or the right hip only was determined by lowest T-score from total hip, femoral neck, or trochanter. RESULTS Despite high left-right correlations of subregion BMD, significant left-right differences in BMD were common: the difference exceeded the LSC for 47% of women at total hip, 31% at femoral neck, and 56% at trochanter. Left-right differences in BMD that exceeded the LSC affected the percent agreement of left-right hip classification: for all women irrespective of spine status, there was 77% classification (diagnostic) agreement in hip pairs in which the left-right hip BMD difference exceeded the LSC versus 87% agreement in which LSC was not exceeded (significant difference in proportions, P<0.0001). The greatest risk of different classification would occur in women with normal spines as the diagnosis might be determined by hip T-scores. Using L1-4 lumbar spine T-scores, 1229 women were normal at the spine. Twenty-four (2%) were osteoporotic at both hips. However, 12 women (1%) were osteoporotic only in the left hip (significantly different from zero, P<0.001) and 11 (1%) only in the right hip (P<0.001); of these 23 women, the difference in BMD between the osteoporotic hip and the contralateral hip exceeded the LSC in 16 (70% of those with osteoporosis in only one hip). Using L1-4 lumbar spine T-scores, 1159 women were osteopenic at the spine. Of these, 126 (11%) were osteoporotic at both hips, 54 (5%) only in the left hip (P<0.001), and 42 (4%) only in the right hip (P<0.001); of these 96 women, the difference in BMD between the osteoporotic hip and the contralateral hip exceeded the LSC in 56 (58% of those with osteoporosis in only one hip). CONCLUSIONS A statistically significant number of women with osteoporosis are potentially classified differently when scanning only one hip as a result of the high prevalence of left-right differences in BMD. Although the percentages are low, the total number of women affected may be large. From a public health perspective, the practice of scanning both hips could potentially identify more women with osteoporosis and may help prevent future hip fractures.
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Affiliation(s)
- R Hamdy
- Osteoporosis Center, College of Medicine, East Tennessee State University and VAMC, Johnson City, TN, USA
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Harris ST, Watts NB, Li Z, Chines AA, Hanley DA, Brown JP. Two-year efficacy and tolerability of risedronate once a week for the treatment of women with postmenopausal osteoporosis. Curr Med Res Opin 2004; 20:757-64. [PMID: 15140343 DOI: 10.1185/030079904125003566] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The efficacy and tolerability of risedronate once-a-week dosing (35 and 50mg) were compared with risedronate daily dosing (5mg) in a 2-year study in women with osteoporosis. DESIGN AND METHODS This was a randomized, double-blind, active-control study with lumbar spine bone mineral density (BMD) as the primary efficacy endpoint at 1 year. Subjects were women aged 50 years or older, postmenopausal for at least 5 years, and had either a BMD T-score of -2.5 or lower (lumbar spine or total proximal femur) or a T-score lower than -2 and at least one prevalent vertebral fracture. In addition to risedronate treatment, the subjects received 1000 mg daily of elemental calcium supplementation and received vitamin D if the baseline serum 25-hydroxyvitamin D(3) level was low. RESULTS The results after 1 year of treatment were previously published. Of the 1456 women who were randomized and received study medication, 1127 (77%) completed the 2-year study. Over the 2 years of treatment, the incidence of both new vertebral fractures (2.9, 1.5, and 1.7% for the 5, 35, and 50 mg groups, respectively; for women with postmenopausal osteoporosis who p = 0.298) and osteoporosis-related non-vertebral fractures reported as adverse events (5.0, 4.9, and 4.5% for the 5, 35, and 50 mg groups, respectively; p = 0.918) was similar for all 3 treatment groups. The reduction from baseline at Month 24 in bone turnover markers was similar based on an analysis of variance for the 5 mg daily and the 35 mg once-a-week groups. The mean percentage change in lumbar spine BMD after 24 months was 5.17, 4.74, and 5.47% for the 5, 35, and 50 mg groups, respectively. Both the 35 and 50 mg once-a-week treatment groups met the pre-specified criterion of non-inferiority to the 5 mg daily treatment group. No apparent difference in the pattern or distribution of serious and upper gastrointestinal adverse events was observed. CONCLUSIONS The 2-year data agree with the 1-year results demonstrating that the risedronate once-a-week doses are comparable in efficacy and safety to the 5 mg daily dose. Risedronate 35 mg once a week is considered the optimal dose want a once-a-week dosing regimen.
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Affiliation(s)
- S T Harris
- University of California, San Francisco, California 94117, USA.
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Rizzoli R, Greenspan SL, Bone G, Schnitzer TJ, Watts NB, Adami S, Foldes AJ, Roux C, Levine MA, Uebelhart B, Santora AC, Kaur A, Peverly CA, Orloff JJ. Two-year results of once-weekly administration of alendronate 70 mg for the treatment of postmenopausal osteoporosis. J Bone Miner Res 2002; 17:1988-96. [PMID: 12412806 DOI: 10.1359/jbmr.2002.17.11.1988] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to provide confirmation that once-weekly dosing with 70 mg of alendronate (seven times the daily oral dose) and twice-weekly dosing with 35 mg is equivalent to the 10-mg once-daily regimen and to gain more extensive safety experience with this new dosing regimen. Twelve hundred fifty-eight postmenopausal women (aged 42-95 years) with osteoporosis (bone mineral density [BMD] of either lumbar spine or femoral neck at least 2.5 SDs below peak young adult mean or prior vertebral or hip fracture) were assigned to receive oral once-weekly alendronate, 70 mg (n = 519); twice-weekly alendronate, 35 mg (n = 369); or daily alendronate 10 mg (n = 370) for a total of 2 years of double-blind experience. Mean BMD increases from baseline (95% CI) at 24 months in the once-weekly, twice-weekly, and daily treatment groups, respectively, were 6.8% (6.4, 7.3), 7.0% (6.6,7.5), and 7.4% (6.9,7.8) at the lumbar spine and 4.1% (3.8,4.5), 4.3% (3.9,4.7), and 4.3% (3.9,4.7) at the total hip. These increases in BMD as well as the BMD increases at the femoral neck, trochanter, and total body and the reductions of biochemical markers of bone resorption (urinary cross-linked N-telopeptides of type I collagen [NTx]) and bone formation (serum bone-specific alkaline phosphatase [BSAP]) were similar for the three dosing regimens. All treatment regimens were well tolerated with a similar incidence of upper gastrointestinal (GI) adverse experiences. The incidence rates of clinical fractures, captured as adverse experiences, were similar among the groups. The 2-year results confirm the conclusion reached after 1 year that once-weekly alendronate is therapeutically equivalent to daily dosing, providing patients with a more convenient dosing option that may potentially enhance adherence to therapy.
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Affiliation(s)
- R Rizzoli
- Department of Internal Medicine, Hõpital Cantonal, Geneva, Switzerland
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Khan AA, Brown J, Faulkner K, Kendler D, Lentle B, Leslie W, Miller PD, Nicholson L, Olszynski WP, Watts NB, Hanley D, Hodsman A, Josse R, Murray TM, Yuen K. Standards and guidelines for performing central dual X-ray densitometry from the Canadian panel of International Society for Clinical Densitometry. J Clin Densitom 2002; 5:247-57. [PMID: 12357062 DOI: 10.1385/jcd:5:3:247] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2002] [Accepted: 03/04/2002] [Indexed: 11/11/2022]
Abstract
The International Society for Clinical Densitometry (ISCD) is a multidisciplinary nonprofit global organization formed to ensure excellence in densitometry imaging, interpretation, and application. The Canadian panel of the ISCD represents ISCD in Canada and oversees Canadian bone densitometry certification programs. The standards of care from the Canadian panel of the ISCD have been developed in order to establish the minimum level of acceptable performance for the practice of bone densitometry in Canada. A variety of techniques are available for skeletal assessment of bone mineral density, which vary in accuracy, precision, and clinical utility as well as availability. This article focuses on central dual X-ray absorptiometry in adults and does not address densitometry in the pediatric population. Other technologies will be addressed in a subsequent article.
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Affiliation(s)
- A A Khan
- McMaster University, Oakville, Ontario, Canada
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Khan AA, Brown J, Faulkner K, Kendler D, Lentle B, Leslie W, Miller PD, Nicholson L, Olszynski WP, Watts NB. Standards and guidelines for performing central dual X-ray densitometry from the Canadian Panel of International Society for Clinical Densitometry. J Clin Densitom 2002; 5:435-45. [PMID: 12665644 DOI: 10.1385/jcd:5:4:435] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2002] [Accepted: 03/04/2002] [Indexed: 11/11/2022]
Abstract
The International Society for Clinical Densitometry (ISCD) is a multidisciplinary nonprofit global organization formed to ensure excellence in densitometry imaging, interpretation, and application. The Canadian panel of the ISCD represents ISCD in Canada and oversees Canadian bone densitometry certification programs. The standards of care from the Canadian panel of the ISCD have been developed in order to establish the minimum level of acceptable performance for the practice of bone densitometry in Canada. A variety of techniques are available for skeletal assessment of bone mineral density, which vary in accuracy, precision, and clinical utility as well as availability. This article focuses on central dual X-ray absorptiometry in adults and does not address densitometry in the pediatric population. Other technologies will be addressed in a subsequent article.
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Affiliation(s)
- A A Khan
- McMaster University, Oakville, Ontario, Canada
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Abstract
Postmenopausal osteoporosis is a widespread condition that affects the physical and emotional well-being of millions of women worldwide. In the clinical trials reviewed here, antiresorptive therapy using the bisphosphonate, risedronate, significantly reduced the incidence of vertebral and nonvertebral fractures, increased BMD in both early and late menopausal women, and decreased biochemical measures of bone resorption. The safety profile of risedronate appears comparable to placebo. These findings demonstrate that risedronate is effective and well tolerated for the prevention and treatment of postmenopausal osteoporosis.
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Affiliation(s)
- N B Watts
- Emory University School of Medicine and Osteoporosis and Bone Health Programs, The Emory Clinic, Atlanta, Georgia 30322, USA
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Hall WD, Pettinger M, Oberman A, Watts NB, Johnson KC, Paskett ED, Limacher MC, Hays J. Risk factors for kidney stones in older women in the southern United States. Am J Med Sci 2001; 322:12-8. [PMID: 11465241 DOI: 10.1097/00000441-200107000-00003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The occurrence of kidney stones is disproportionate in the southern region of the United States. Risk factors for the occurrence of kidney stones in this geographic area have not been reported previously. METHODS The Women's Health Initiative (WHI) is an ongoing multicenter clinical investigation of strategies for the prevention of common causes of morbidity and mortality among postmenopausal women. A case-control ancillary study was conducted on 27,410 (white or black) women enrolled in the 9 southern WHI clinical centers. There were 1,179 cases (4.3%) of kidney stones at the baseline evaluation. Risk factors for stone formation were assessed in cases versus age- and race-matched control subjects. RESULTS Risk factors (univariate) included low dietary potassium (2,404 versus 2,500 mg/day, P = 0.006), magnesium (243 versus 253 mg/day, P = 0.003) and oxalate (330 versus 345 mg/day, P = 0.02) intake, as well as increased body mass index (28.5 versus 27.7 kg/m2, P = 0.001) and a history of hypertension (42% versus 34%, P = 0.001). A slightly lower dietary calcium intake (683 versus 711 mg/day, P = 0.04) was noted in case subjects versus control subjects, but interpretation was confounded by the study of prevalent rather than incident cases. Supplemental calcium intake >500 mg/day was inversely associated with stone occurrence. CONCLUSION Multivariate risk factors for the occurrence of kidney stones in postmenopausal women include a history of hypertension, a low dietary intake of magnesium, and low use of calcium supplements.
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Affiliation(s)
- W D Hall
- Emory University School of Medicine, Atlanta, Georgia, USA.
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Abstract
Osteoporosis is a significant public health problem. Vertebral fractures are the most common fracture in patients with osteoporosis, occurring in approximately 750,000 cases each year. The fractures may cause acute or chronic pain, reduce the quality of life, and shorten life expectancy. Several medications are available that reduce the risk of fracture. Vertebroplasty and kyphoplasty (balloon-inflated expansion of collapsed vertebrae followed by injection of bone cement) may reduce or relieve pain in selected patients. Although surgery is rarely necessary for the management of osteoporotic vertebral fractures, it may be indicated for other reasons. No studies have been conducted to determine if the outcome of spinal fusion is different in patients with osteoporosis and, if it is, whether management of the patient's osteoporosis will improve the outcome.
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Affiliation(s)
- N B Watts
- The Emory Clinic, Emory University School of Medicine, Atlanta, Georgia, USA.
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35
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Abstract
Bisphosphonates are safe and effective agents for treatment and prevention of osteoporosis. Alendronate and risedronate are the best studied of all agents for osteoporosis in terms of efficacy and safety. They increase bone mass. In patients who have established osteoporosis, they reduce the risk of vertebral fractures. They are the only agents shown in prospective trials to reduce the risk of hip fractures and other nonvertebral fractures. They are approved by the US FDA for prevention of bone loss in recently menopausal women, for treatment of postmenopausal osteoporosis, and for management of glucocorticoid-induced bone loss. Other bisphosphonates (e.g., etidronate for oral use, pamidronate for intravenous infusion) are also available and can be used off-label for patients who cannot tolerate approved agents. Bisphosphonates combined with estrogen produce greater gains in bone mass compared with either agent used alone; whether there is a greater benefit of combination therapy on fracture risk is not clear. Combining a bisphosphonate with raloxifene or calcitonin is probably safe, although data on effectiveness are lacking.
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Affiliation(s)
- N B Watts
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.
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Abstract
Vertebral fracture is the most common complication of osteoporosis. It results in significant mortality and morbidity, including prolonged and intractable pain in a minority of patients. Vertebroplasty and kyphoplasty, procedures that involve percutaneous injection of bone cement into a collapsed vertebra, have recently been introduced for treatment of osteoporotic patients who have prolonged pain (several weeks or longer) following vertebral fracture. To determine the details of the procedures and to gather information on their safety and efficacy, we performed a MEDLINE search using the terms 'vertebroplasty' and 'kyphoplasty.' We reviewed reports of these procedures in patients with osteoporosis. We supplemented the articles found with other papers known to the authors and with presentations at national meetings. Randomized trials of vertebroplasty and kyphoplasty have not been reported. Case reports suggest that these procedures are associated with pain relief in 67% to 100% of cases. Short-term complications, mainly the result of extravasation of cement, include increased pain and damage from heat or pressure to the spinal cord or nerve roots. Proper patient selection and good technique should minimize complications, but rarely, decompressive surgery is needed. Long-term benefits have not yet been shown, but potentially include prevention of recurrent pain at the treated level(s) with both procedures, and, with kyphoplasty, reversal of height loss and spinal deformity, an improved level of function, and avoidance of chronic pain and restriction of internal organs. Possible long-term complications, again not fully evaluated, include local acceleration of bone resorption caused by the treatment itself or by foreign-body reaction at the cement-bone interface, and increased risk of fracture in treated or adjacent vertebrae through changes in mechanical forces. Controlled trials are needed to determine both short-term and long-term safety and efficacy of vertebroplasty and kyphoplasty. Both procedures may be useful for osteoporotic patients who have prolonged pain following acute vertebral fracture. Until there is conclusive evidence for efficacy and long-term safety, these procedures should be done only in carefully selected patients, only by experienced operators with appropriate high-quality imaging equipment, and ideally at centers that are participating in controlled trials.
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Affiliation(s)
- N B Watts
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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Lenchik L, Watts NB. Regression to the mean: what does it mean? Using bone density results to monitor treatment of osteoporosis. J Clin Densitom 2001; 4:1-4. [PMID: 11309514 DOI: 10.1385/jcd:4:1:01] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2000] [Revised: 11/27/2000] [Accepted: 12/05/2000] [Indexed: 11/11/2022]
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Watts NB, Jenkins DK, Visor JM, Casal DC, Geusens P. Comparison of bone and total alkaline phosphatase and bone mineral density in postmenopausal osteoporotic women treated with alendronate. Osteoporos Int 2001; 12:279-88. [PMID: 11420777 DOI: 10.1007/s001980170117] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Alendronate therapy in osteoporotic women decreases bone turnover and increases bone mineral density (BMD). Optimal patient management should include verification that each patient is responding to therapy. Markers of bone turnover and BMD have both been proposed for this purpose. We have investigated changes resulting from alendronate therapy with an enzyme immunoassay for bone alkaline phosphatase (BAP) and compared it with total alkaline phosphatase (TAP) and BMD of the lumbar spine, hip, and total body. Subjects were drawn from a multicenter randomized, placebo-controlled trial of alendronate in postmenopausal women with osteoporosis. BAP and TAP levels were measured at baseline and following 3, 6 and 12 months of therapy with either placebo (n = 180) or alendronate 10 mg/day (n = 134). All subjects also received 500 mg/day supplemental calcium. BMD was measured at baseline and following 3, 6, 12, 18, 24 and 36 months of therapy. To compare BAP, TAP and BMD at each site for identifying women that experienced a skeletal effect of alendronate, we calculated least significant change (LSC) values from the long-term intraindividual variability in each placebo-treated woman. Median levels of BAP decreased by 34%, 44% and 43% at 3, 6 and 12 months, respectively, in alendronate-treated women (p < 0.0001 compared with baseline and with placebo). These changes were significantly greater (p < 0.0001) than changes observed for TAP. Following 6 months of alendronate therapy, 90% of the women had experienced a decrease in BAP exceeding the LSC compared with only 71% for TAP. The greatest number of women similarly identified with BMD at any site (i.e. a gain in BMD exceeding the LSC) was 81% for spinal BMD at 36 months. All other sites were less than 70% at 36 months. Short-term changes in BAP and TAP were modestly associated with subsequent changes in BMD at all sites (Spearman's rho -0.22 to -0.52, p < 0.05). Compared with TAP and BMD, BAP testing rapidly and sensitively identified skeletal effects of alendronate thus enabling appropriate drug monitoring of osteoporotic women. Though BAP and TAP changes were modestly predictive of BMD changes, the value of the bone marker tests is their ability to detect rapidly a skeletal effect of therapy.
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Affiliation(s)
- N B Watts
- Emory University School of Medicine, Atlanta, GA, USA.
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Abstract
Osteoporosis is a common and costly condition that can cause disability or death. Evaluation of patients for possible secondary causes is important. Bone density testing permits identification of individuals who are at high risk of fracture and is recommended for all women age 65 and older and for younger women who have clinical risk factors. Measurement of bone markers, particularly collagen cross links, may add some information. Adequate calcium, vitamin D, and weight-bearing exercise are important for everyone and are fundamental to any program for prevention of bone loss or treatment of osteoporosis. Effective pharmacologic agents are available for prevention of bone loss in recently menopausal women and for treatment of established osteoporosis. Pharmacologic intervention is indicated for women who have osteoporosis, defined either as a fracture or BMD T-score of -2.5 and below.
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Affiliation(s)
- N B Watts
- Emory University School of Medicine, Osteoporosis and Bone Health Program, The Emory Clinic, Atlanta, Georgia 30322, USA.
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Watts NB, Nolan JC, Brennan JJ, Yang HM. Esterified estrogen therapy in postmenopausal women. Relationships of bone marker changes and plasma estradiol to BMD changes: a two-year study. Menopause 2000; 7:375-82. [PMID: 11127759 DOI: 10.1097/00042192-200011000-00002] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine the relationships among bone mineral density changes, bone marker changes, and plasma estrogens in postmenopausal women receiving estrogen replacement therapy. DESIGN A total of 406 postmenopausal women received 1,000 mg calcium and continuous esterified estrogens (0.3 mg, 0.625 mg, or 1.25 mg) or placebo daily for up to 24 months. Bone mineral density and bone marker measurements were determined at 6-month intervals; plasma estrogens were measured in a subset after 12, 18, and 24 months. RESULTS Esterified estrogens produced significant increases in bone mineral density (lumbar spine, hip) compared with baseline and placebo at 6, 12, 18, and 24 months. Bone markers decreased from baseline with all esterified estrogen doses relative to placebo. Bone marker changes at 6 months correlated negatively with bone mineral density changes at 24 months (correlation coefficient range = -0.122 to -0.439). The strongest correlation was noted for spine bone mineral density changes and serum osteocalcin. Mean plasma estrogen levels increased with esterified estrogen dose, and bone mineral density changes correlated positively with plasma estrogen levels. Positive bone mineral density changes were noted in treatment groups with plasma estradiol levels at and above 25 pg/mL. CONCLUSIONS Esterified estrogens, at doses from 0.3 mg to 1.25 mg/day, unopposed by progestin, increase bone mineral density of the spine and hip in postmenopausal women. These bone mineral density changes correlated significantly with bone marker changes at 6 months and with plasma estrogens at 12, 18, or 24 months. Data variability minimizes the predictive value of the bone marker changes in monitoring individual therapy.
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Affiliation(s)
- N B Watts
- Emory University, Atlanta, Georgia, USA
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Greenspan SL, Harris ST, Bone H, Miller PD, Orwoll ES, Watts NB, Rosen CJ. Bisphosphonates: safety and efficacy in the treatment and prevention of osteoporosis. Am Fam Physician 2000; 61:2731-6. [PMID: 10821153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Osteoporosis affects more than 28 million Americans. With the advent of accessible and affordable diagnostic studies, awareness and recognition of this disease by patients and clinicians are growing. Osteoporotic fractures of the spine and hip are costly and associated with significant morbidity and mortality. Over the past decade, a surge of new antiosteoporotic drugs have been labeled or are awaiting labeling by the U.S. Food and Drug Administration. One class of agents used to treat osteoporosis is the bisphosphonates, which inhibit bone resorption, cause an increase in bone mineral density and reduce the risk of future fractures caused by aging, estrogen deficiency and corticosteroid use. Overall, bisphosphonates have been shown to have a strong safety and tolerability profile.
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Affiliation(s)
- S L Greenspan
- University of Pittsburgh School of Medicine, Pennsylvania, USA
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Looker AC, Bauer DC, Chesnut CH, Gundberg CM, Hochberg MC, Klee G, Kleerekoper M, Watts NB, Bell NH. Clinical use of biochemical markers of bone remodeling: current status and future directions. Osteoporos Int 2000; 11:467-80. [PMID: 10982161 DOI: 10.1007/s001980070088] [Citation(s) in RCA: 155] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Biochemical markers of bone turnover provide a means of evaluating skeletal dynamics that complements static measurements of bone mineral density (BMD). This review evaluates the use of commercially available bone turnover markers as aids in diagnosis and monitoring response to treatment in patients with osteoporosis. High within-person variability complicates but does not preclude their use. Elevated bone resorption markers appear to be associated with increased fracture risk in elderly women, but there is less evidence of a relationship between bone formation markers and fracture risk. The critical question of predicting fracture efficacy with treatment has not been answered. Changes in bone markers as currently determined do not predict BMD response to either bisphosphonates or hormone replacement therapy. Single measurements of markers do not predict BMD cross-sectionally (except possibly in the very elderly), or change in BMD in individual patients, either treated or untreated. On the other hand, research applications of bone turnover markers are of value in investigating the pathogenesis and treatment of bone diseases. Markers have potential in the clinical management of osteoporosis, but their use in this regard is not established. Additional studies with fracture endpoints and information on negative and positive predictive value are needed to evaluate fully the utility of bone turnover markers in individual patients.
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Affiliation(s)
- A C Looker
- National Osteoporosis Foundation, Washington, DC, USA
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Watts NB, Miller PD. Changing perceptions in osteoporosis. Markers should be used as adjunct to bone densitometry. BMJ 1999; 319:1371-2. [PMID: 10617345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
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Harris ST, Watts NB, Genant HK, McKeever CD, Hangartner T, Keller M, Chesnut CH, Brown J, Eriksen EF, Hoseyni MS, Axelrod DW, Miller PD. Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. Vertebral Efficacy With Risedronate Therapy (VERT) Study Group. JAMA 1999; 282:1344-52. [PMID: 10527181 DOI: 10.1001/jama.282.14.1344] [Citation(s) in RCA: 1555] [Impact Index Per Article: 62.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
CONTEXT Risedronate, a potent bisphosphonate, has been shown to be effective in the treatment of Paget disease of bone and other metabolic bone diseases but, to our knowledge, it has not been evaluated in the treatment of established postmenopausal osteoporosis. OBJECTIVE To test the efficacy and safety of daily treatment with risedronate to reduce the risk of vertebral and other fractures in postmenopausal women with established osteoporosis. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, placebo-controlled trial of 2458 ambulatory postmenopausal women younger than 85 years with at least 1 vertebral fracture at baseline who were enrolled at 1 of 110 centers in North America conducted between December 1993 and January 1998. INTERVENTIONS Subjects were randomly assigned to receive oral treatment for 3 years with risedronate (2.5 or 5 mg/d) or placebo. All subjects received calcium, 1000 mg/d. Vitamin D (cholecalciferol, up to 500 IU/d) was provided if baseline levels of 25-hydroxyvitamin D were low. MAIN OUTCOME MEASURES Incidence of new vertebral fractures as detected by quantitative and semiquantitative assessments of radiographs; incidence of radiographically confirmed nonvertebral fractures and change from baseline in bone mineral density as determined by dual x-ray absorptiometry. RESULTS The 2.5 mg/d of risedronate arm was discontinued after 1 year; in the placebo and 5 mg/d of risedronate arms, 450 and 489 subjects, respectively, completed all 3 years of the trial. Treatment with 5 mg/d of risedronate, compared with placebo, decreased the cumulative incidence of new vertebral fractures by 41 % (95% confidence interval [CI], 18%-58%) over 3 years (11.3 % vs 16.3%; P= .003). A fracture reduction of 65% (95% CI, 38%-81 %) was observed after the first year (2.4% vs 6.4%; P<.001). The cumulative incidence of nonvertebral fractures over 3 years was reduced by 39% (95% CI, 6%-61 %) (5.2 % vs 8.4%; P = .02). Bone mineral density increased significantly compared with placebo at the lumbar spine (5.4% vs 1.1 %), femoral neck (1.6% vs -1.2%), femoral trochanter (3.3% vs -0.7%), and midshaft of the radius (0.2% vs -1.4%). Bone formed during risedronate treatment was histologically normal. The overall safety profile of risedronate, including gastrointestinal safety, was similar to that of placebo. CONCLUSIONS These data suggest that risedronate therapy is effective and well tolerated in the treatment of women with established postmenopausal osteoporosis.
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Affiliation(s)
- S T Harris
- University of California, San Francisco 94117-3608, USA
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Watts NB. Clinical utility of biochemical markers of bone remodeling. Clin Chem 1999; 45:1359-68. [PMID: 10430819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Remodeling is essential for bone health. It begins with resorption of old bone by osteoclasts, followed by the formation of new bone by osteoblasts. Remodeling is coupled (formation is linked to resorption). After middle age or perhaps beginning earlier, bone loss occurs because resorption exceeds formation. This imbalance is accentuated by estrogen deficiency as well as by many diseases and conditions. Biochemical markers that reflect remodeling and can be measured in blood or urine include resorption markers (e.g., collagen cross-links) and formation markers (e.g., alkaline phosphatase). Bone markers exhibit substantial short-term and long-term fluctuations related to time of day, phase of the menstrual cycle, and season of the year, as well as diet, exercise, and anything else that alters bone remodeling. These biological factors, in addition to assay imprecision, produce significant intra- and interindividual variability in markers. Bone marker measurements are noninvasive, inexpensive, and can be repeated often. Unfortunately, most of the studies that provided insight on clinical situations did not focus on markers as a primary endpoint. Bone markers have been useful in clinical practice and have been helpful in understanding the pathogenesis of osteoporosis and the mechanism of action of therapies. In clinical trials, markers aid in selecting optimal dose and in understanding the time course of onset and resolution of treatment effect. Clinical questions that might be answered by bone markers include diagnosing osteoporosis, identifying "fast bone losers" and patients at high risk of fracture, selecting the best treatment for osteoporosis, and providing an early indication of the response to treatment. Additional information is needed to define specific situations and cut points to allow marker results to be used with confidence in making decisions about individual patients.
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Affiliation(s)
- N B Watts
- Emory University School of Medicine, Atlanta, GA 30322, USA.
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Abstract
UNLABELLED Osteoporosis affects approximately 28 million Americans and costs about $14 billion a year. Low bone density is the most important risk factor for osteoporosis. The National Osteoporosis Foundation recommends bone density testing for all women over 65 and earlier (around the time of menopause) for women who have risk factors or who are considering therapy. Biochemical markers of bone remodeling, such as urine collagen cross links, may be useful to decide if treatment is needed and to determine the effectiveness of treatment. Once the diagnosis of osteoporosis is made, it is time to consider management options. A healthy life style is important for everyone: an adequate intake of calcium and vitamin D and regular weight-bearing exercise. Pharmacologic agents are indicated for all patients with fragility fractures and for many patients with low bone density. Estrogen is the agent of choice for both prevention and treatment of postmenopausal osteoporosis; however, once estrogen is stopped, bone mass levels drop fairly quickly. Long-term adherence to hormone replacement therapy is not good. Effective alternatives for prevention of bone loss in recently menopausal women include alendronate (a bisphosphonate) and raloxifene (a selective estrogen-receptor modulator). Effective alternatives for treatment of established osteoporosis include alendronate and nasal calcitonin. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES After completion of this article, the reader will be able to understand the clinical impact and sequlae of osteoporosis in women, how to identify the high risk patient and those patient that should be screened, the various tests that are available for screening and monitoring, and the various pharmacologic therapies for osteoporosis.
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Affiliation(s)
- N B Watts
- Osteoporosis and Bone Health Program, Emory Clinic, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Abstract
The Bone Mass Measurement Act (BMMA) set forth regulations to provide for uniform coverage under Medicare Part B for bone mass measurements for services provided on or after July 1, 1998. The BMMA authorizes Medicare coverage of "medically necessary approved measurements" performed for a "qualified individual" who falls into at least one of five diagnostic categories: an estrogen-deficient woman at clinical risk for osteoporosis; an individual with vertebral abnormalities; an individual receiving long-term glucocorticoid (steroid) therapy; an individual with primary hyperparathyroidism; and an individual being monitored to assess the response to, or efficacy of, an approved osteoporosis drug therapy. Proper communication is essential for reimbursement. The tools for communication include Physician's Current Procedural Terminology (CPT), HCFA (Health Care Financing Administration) Common Procedure Coding System (HCPCS), the Medicare carrier's local Medical Review Policy (LMRP), and the International Classification of Diseases, ninth revision (ICD-9). This article reviews the new regulations and the tools for communication.
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Abstract
In a U.S. multicenter study of intermittent cyclical etidronate treatment for postmenopausal osteoporosis, approximately 20% of patients were nonresponders, defined as failure to increase spine bone mineral density. In contrast, essentially all patients who received 10 mg of alendronate daily in U.S. phase III trials showed some increase in spine bone mineral density. The current study was undertaken to determine the response to alendronate therapy in women with postmenopausal osteoporosis who were nonresponders to intermittent cyclical etidronate therapy. Twenty-five women with postmenopausal osteoporosis (mean +/- SD: 65.1+/-1.9 years of age), previously treated with intermittent cyclical etidronate with no increase of spine bone mineral density, and who agreed to be changed to alendronate, were recruited from a university out-patient clinic specializing in the treatment of osteoporosis for a prospective observational study. Measurements included bone mineral density of the lumbar spine and proximal femur (by dual-energy X-ray absorptiometry) and biochemical markers of bone remodeling (serum bone-specific alkaline phosphatase by immunoassay and urine deoxypyridinoline by high-pressure liquid chromatography). Patients had received intermittent cyclical etidronate for 3.3+/-0.4 years, during which time their bone density declined at spine and hip sites. They were then changed to alendronate 10 mg/day, which they received for 1.3+/-0.1 years; after treatment with alendronate, bone mineral density increased significantly at the lumbar spine (4.4+/-0.7% annualized,p < 0.0001) and at all hip sites. Bone markers also changed significantly after alendronate treatment: urine deoxypyridinoline fell from 6.8+/-0.8 to 5.5+/-0.6 micromol/mol creatinine (p < 0.0001) and serum bone-specific alkaline phosphatase rose from 4.6+/-0.5 to 11.9+/-1.0 ng/mL (p < 0.0001). Upper gastrointestinal side effects forced 4 of 25 patients (16%) to discontinue alendronate. Alendronate increases bone density at the spine and hip in patients who have not responded to intermittent cyclical etidronate therapy. Changes in bone markers suggest that alendronate causes more complete suppression of bone resorption and less inhibition (or stimulation) of bone formation.
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Affiliation(s)
- N B Watts
- Emory University School of Medicine, Atlanta, GA, USA.
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Miller PD, Baran DT, Bilezikian JP, Greenspan SL, Lindsay R, Riggs BL, Watts NB. Practical clinical application of biochemical markers of bone turnover: Consensus of an expert panel. J Clin Densitom 1999; 2:323-42. [PMID: 10548827 DOI: 10.1385/jcd:2:3:323] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/1999] [Revised: 04/26/1999] [Accepted: 05/03/1999] [Indexed: 11/11/2022]
Abstract
Biochemical markers of bone turnover have emerged as powerful tools to aid in managing osteoporosis. The newer bone markers have been intensively studied for more than a decade. As a result, we can now confidently report their clinical utility in assessing risk of rapid bone loss and fracture, and monitoring therapy in postmenopausal women with or at risk of osteoporosis. In this review, we will provide a comprehensive foundation for this utility. While there are still questions remaining to be answered, bone marker technology has matured to play an essential role in patient management. We will describe, in practical terms, how bone markers can be appropriately incorporated into clinical practice today.
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Affiliation(s)
- P D Miller
- Department of Medicine, University of Colorado Health Sciences Center and Colorado Center for Bone Research, Denver, CO 80227, USA.
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