Management of Osteoporosis in Survivors of Adult Cancers With Nonmetastatic Disease: ASCO Clinical Practice Guideline.

Abstract: The aim of this work is to provide evidence-based guidance on the management of osteoporosis in survivors of adult cancer.ASCO convened a multidisciplinary Expert Panel to develop guideline recommendations […]

» Read more

Prevalence and risk factors for osteoporosis in individuals with chronic obstructive pulmonary disease: a systematic review and meta-analysis.

Osteoporosis is prevalent in individuals with chronic obstructive pulmonary disease (COPD). Updated evidence is required to complement the previous systematic review on this topic in order to provide best practice. The aim of this systematic review and meta-analysis was to quantitatively synthesize data from studies with respect to the prevalence and risk factors for osteoporosis among individuals with COPD.EMBASE, CINAHL MEDLINE, and PubMed databases were searched for articles containing the keywords “COPD”, “osteoporosis”, “prevalence”, and “risk factor”. Eligibility screening, data extraction, and quality assessment of the retrieved articles were conducted independently by two reviewers. Meta-analyses were performed to determine osteoporosis prevalence and risk factors in individuals with COPD. Meta-regression analyses were conducted to explore the sources of heterogeneity.The pooled global prevalence from 58 studies was 38% (95% CI= 34, 43). The presence of COPD increased the likelihood of having osteoporosis (OR= 2.83). Other significant risk factors for osteoporosis in COPD patients were body mass index < 18.5 kg/m2 (OR=4.26) and the presence of sarcopenia (OR= 3.65).Osteoporosis is prevalent in individuals with COPD and the prevalence appears to be high and similar in many countries. COPD patients should be screened for osteoporosis and contributing risk factors.

» Read more

Neglected bodily senses in women living with vertebral fracture: a focus group study.

Older women are at particular risk of osteoporosis. Among women with osteoporosis, fractures of the vertebra (vertebral fracture) are common, hard to detect and associated with risk of further fracture. Identifying vertebral fracture in a timely manner allows instigation of preventive measures to reduce the risk of further fracture. Although detection of vertebral fracture requires spinal radiograph, many women do not receive referral. To begin development of a screening tool to identify women in need of referral we undertook a qualitative study to characterize women’s experiences of vertebral fracture, using Eccleston’s ‘Ten Neglected Bodily Senses’.Four qualitative focus groups were conducted with women who had been diagnosed with vertebral fracture (n = 19, age 60-91 years). Data were audio-recorded, transcribed and analysed thematically using the ‘Ten Neglected Bodily Senses’.Women’s experiences of vertebral fractures related to seven senses: pain, movement, fatigue, balance, pressure, appetite and breathing. Pain was the dominant sense and all participants explained how pain increased with activity, reaching a crescendo, and described strategies to minimize this disruption. Most participants had become physically shorter, making some feel ‘squashed’, putting pressure on other body parts. Some described appetite loss or a sense of restricted breathing. Participants experienced a sense of being ‘pulled’ forwards, impacting on balance and exacerbating fear of falling.The study found senses that have not been previously described in the experiences of women with vertebral fracture. These will be used to inform the design of a new screening tool for use in primary care.

» Read more

Predictors of Poor Bone Microarchitecture Assessed by Trabecular Bone Score (TBS) in Postsurgical Hypoparathyroidism.

The effects of parathyroid hormone deprivation on bone are still unclear. Our objective was to report the characteristics of patients with postsurgical hypoparathyroidism (PsH) at a specialized outpatient service and correlate their trabecular bone score (TBS) values to clinical, densitometric, and laboratory findings. A secondary objective was to evaluate the fracture rates and look for associations between these events and the collected data.Eighty-two patients were enrolled, of whom 70 (85.4%) were female and 17 (20.7%) had type 2 diabetes mellitus (T2DM). The median body mass index (BMI) was 27.7 kg/m2 and the median age was 59 years. Of 68 DXA scans performed, osteopenia and osteoporosis were present in 32.4% and 2.9%, respectively. In all, 62 lumbar scans were analyzed using TBS. The mean TBS value was 1.386±0.140, and 32.2% of the results were below 1.310. TBS values correlated negatively with BMI (mainly above 30kg/m2), age (mainly above 60 years), and glycemia, while abnormal TBS correlated with osteopenia, T2DM, low impact fracture, and menopause. Six female patients had low impact fractures, which were associated with a lower TBS (1.178±0.065 vs. 1.404±0.130 in the group without fractures, p<0.001), greater age, higher BMI, impaired renal function, abnormal glycemia, and osteopenia.This study suggested that known risk factors for bone loss compromise the bone microarchitecture of individuals with PsH, despite DXA results. PsH menopausal women, PsH patients who are older, osteopenic and have a higher BMI or T2DM may be candidates for a more detailed assessment using, for example, TBS.

» Read more

Endocrine and metabolic disorders in survivors of childhood cancers and health-related quality of life and physical activity.

Childhood cancer survivors experience chronic health conditions that impact health related quality of life (HRQOL) and participation in optimal physical activity.The study aimed to determine independent effects of endocrine and metabolic disorders on HRQOL and physical activity.Retrospective cohort with longitudinal follow-up of survivors of childhood cancer enrolled in the North American Childhood Cancer Survivor Study.Medical Outcomes Short Form-36 estimated HRQOL while participation in physical activity was dichotomized as meeting or not meeting recommendations from the Center for Disease Control and Prevention. Log binomial regression evaluated the association of each endocrine/metabolic disorder with HRQOL scales and physical activity.Of 7,287 survivors, median age 32 years (18-54) at their last follow-up survey, 4,884 (67%) reported one or more endocrine/metabolic disorders. Survivors with either disorder were significantly more likely to be male, older, received radiation treatment, and experience other chronic health conditions. After controlling for covariates, survivors with any endocrine/metabolic disorder were more likely to report poor physical function risk ratio ([RR] 1.25; 95% confidence interval [CI] 1.05-1.48), increased bodily pain (RR 1.27; CI 1.12-1.44), poor general health (RR 1.49; CI 1.32-1.68) and lower vitality (RR 1.21; CI 1.09-1.34) compared to survivors without. The likelihood of meeting recommended physical activity was lower among survivors with growth disorders (RR 0.90; CI=0.83-0.97), osteoporosis (RR 0.87; CI=0.76-0.99), and overweight/obesity (RR 0.92; CI 0.88-0.96).Endocrine and metabolic disorders are independently associated with poor HRQOL and sub-optimal physical activity among childhood cancer survivors.

» Read more

Comparison of Teriparatide and Denosumab in Patients Switching from Long-Term Bisphosphonate Use.

Teriparatide and denosumab are effective treatments for osteoporosis and typically reserved as second-line options after patients have used bisphosphonates. However, limited head-to-head comparative effectiveness data exist between teriparatide and denosumab.We compared changes in bone mineral density (BMD) between groups treated with teriparatide or denosumab after using bisphosphonates, focusing on the change in BMD while on either drug over 2 years.Observational cohort study using electronic medical records from two academic medical centers in the US.The study population included osteoporotic patients > 45 years who received bisphosphonates over one year prior to switching to teriparatide or denosumab.Annualized BMD change from baseline at the lumbar spine, total hip and femoral neck.Patients treated with teriparatide (n=110) were compared to those treated with denosumab (n=105); the mean (SD) age was 70 (10) years and median duration (IQR) of bisphosphonate use was 7.0 (5.6-9.7) years. Compared to denosumab users, teriparatide users had higher annualized BMD change at the spine by 1.3% (95% CI 0.02, 2.7%), but lower at the total hip by -2.2% (95% CI -2.9 to -1.5%) and the femoral neck by -1.1% (95% CI -2.1 to -0.1%). Those who switched to teriparatide had a transient loss of hip BMD for the first year, with no overall increase in the total hip BMD over two years.Among patients who use long-term bisphosphonates, the decision of switching to teriparatide should be made with caution, especially for patients at high risk of hip fracture.

» Read more

Association between urinary triclosan with bone mass density and osteoporosis in the US adult women, 2005-2010.

Laboratory studies have demonstrated that Triclosan (TCS) could result in significant interstitial collagen accumulation and an increase in trabecular bone. However, little is known about the relationship between TCS exposure and human bone health.We used 2005-2010 National Health and Nutrition Examination Survey data to examine the association between urinary TCS concentrations with BMD and osteoporosis in the US adult women (age ?20 years). After inclusion and exclusion, 1,848 women were finally analyzed.After adjustment for other covariates, we observed significant associations between tertile 3 of TCS concentration and lower BMD in regions of total femur (?=-0.016, 95% CI=-0.032, -0.000), intertrochanter (?=-0.022, 95% CI=-0.042, -0.002), and lumbar spine (?=-0.014, 95% CI=-0.029, 0.001), respectively, relative to tertile 1. Compared with women at tertile 1, those at tertile 3 were more likely to have increased osteoporosis prevalence in intertrochanter [odd ratio (OR)=2.464, 95% CI = 1.190, 5.105].this is the first epidemiological study to investigate the association between urinary TCS concentration with BMD and osteoporosis in the US adult women. We found urinary TCS concentration was negatively associated with BMD and was positively associated with the prevalence of osteoporosis. The evidence was stronger in postmenopausal women than in premenopausal women. Future prospective studies are needed to validate the findings.

» Read more

Testing and management for monoclonal gammopathy of uncertain significance and myeloma patients presenting with osteoporosis and fragility fractures.

Multiple myeloma, the second most frequent blood cancer, and its precursor, monoclonal gammopathy of uncertain significance, are associated with an increased risk of fragility fractures. However, current guidelines fail to offer explicit indications for healthcare professionals in terms of testing and thresholds for onward referral. The purpose of this review is to present the association of these conditions and metabolic bone disease and to highlight the importance of considering a diagnosis of monoclonal gammopathy of uncertain significance and myeloma in the context of a secondary fracture prevention assessment and of a multidisciplinary approach in managing these patients.

» Read more

Management of pancreatic exocrine insufficiency.

Pancreatic exocrine insufficiency (PEI) is one of the well known causes of malabsorption syndrome. An insufficient secretion of pancreatic enzymes and bicarbonate secondary to different pancreatic diseases and upper gastrointestinal and pancreatic surgery leads to maldigestion and malabsorption of nutrients. Patients with PEI may present with symptoms of malabsorption and different nutritional deficiencies. Recent data support the high clinical relevance of PEI and its treatment.Deficiencies of fat-soluble vitamins, proteins, micronutrients and antioxidants in patients with PEI are associated not only with an increased risk of osteoporosis and sarcopenia but also of cardiovascular events and mortality. Pancreatic enzyme replacement therapy (PERT) allows improving fat and protein digestion, relieving maldigestion-related symptoms, normalizing the nutritional status, and improving quality of life of patients with PEI. Recent data support the efficacy of PERT on survival in patients with pancreatic cancer. Dose of oral pancreatic enzymes should be adequate to normalize the nutritional status of PEI patients.Increasing evidence supports the relevance of PEI management by dietary advice and appropriate PERT. Well designed and powered randomized, placebo-controlled clinical trials are needed to further evaluate the clinical impact of PEI and its treatment in clinical practice.

» Read more

Identifying and Addressing Osteoporosis Knowledge Gaps in Women with Premature Ovarian Insufficiency and Early Menopause: A mixed methods study.

Osteoporosis associated with premature ovarian insufficiency (POI) and early menopause (EM) is a major concern for women. We aimed to (i) identify information and knowledge gaps and behaviours regarding bone health in women with POI/EM; and (ii) co-design an osteoporosis factsheet.Mixed-methods study: survey of women and online resource appraisals to develop and refine, using semi-structured interviews, an osteoporosis factsheet.Women with POI/EM (menopause before ages 40 and 45 years respectively).Demographics, comorbidities, information needs, calcium intake, exercise, osteoporosis knowledge (OKAT), beliefs and self-efficacy, DISCERN appraisal (validated scales).descriptive statistics, logistic regression and thematic analysis of interviews.Median age of survey respondents (n=316) was 54(IQR47-63) years, median age of menopause was 40(IQR38-43) years, and osteoporosis diagnosis was reported in 19%. Most reported inadequate dietary calcium intake (99%) and exercise (65%). Median OKAT score 8[IQR6-10]/19 indicated knowledge gaps regarding risk factors and treatment options. Adjusting for age and education, OKAT predicted calcium intake [OR1.126(CI 1.035-1.225); p=0.006) and screening [OR1.186(CI 1.077-1.305; p=0.001); beliefs predicted screening [OR1.027(CI 1.004-1.050); p=0.019]; and self-efficacy predicted calcium intake [OR1.040(CI 1.013-1.069); p=0.003] and exercise [OR1.117(CI 1.077-1.160); p<0.001]. Current online resources have deficiencies. Five themes identified from 2 interview rounds (n=10/ round) were: content, emotional response, design, perceived usefulness and clinical considerations. The final factsheet was considered acceptable and useful in addressing knowledge gaps, promoting information-seeking, impacting behaviours and facilitating healthcare discussions.A co-designed factsheet is acceptable and addresses identified osteoporosis knowledge gaps in women with POI/EM. This article is protected by copyright. All rights reserved.

» Read more

Transdermal delivery of fluvastatin loaded nanoemulsion gel: Preparation, characterization and in vivo anti-osteoporosis activity.

The objective of present study was to develop hydrogel based nanoemulsion (NE) drug delivery system for transdermal delivery and evaluate its potential in in vivo anti-osteoporotic activity. NE was prepared using aqueous phase titration method and characterized for droplet size, zeta potential and morphology. It was then formulated into hydrogel based NE gel using carbopol 940 as gelling agent. NE gel was evaluated for pH, viscosity, in vitro/ex vivo permeation studies and in vivo anti-osteoporotic activity. The results indicated formation of spherical, nano sized globules of NE ranging from 11.17?±?0.24 to 128.8?±?0.16?nm with polydispersity of <0.5. In vitro and ex vivo permeation studies showed significantly higher permeation of NE as well as NE gel in comparison to fluvastatin solution indicating that NE gel can effectively penetrate through skin layers. In vivo anti-osteoporotic results demonstrated formation of new bone in trabecular region of osteoporotic rat femurs through micro-CT scanning radiographs. Biomechanical strength testing demonstrated greater load bearing capacity of rat femurs in the treated animals in comparison with the osteoporotic group. Thus, developed NE gel formulation of fluvastatin demonstrated greater potential for transdermal delivery and in the treatment of osteoporosis.

» Read more

A System to Determine Risk of Osteoporosis in Patients With Autoimmune Hepatitis.

Osteoporosis is a feared complication of autoimmune hepatitis (AIH), but bone disease has not been well studied in these patients. We aimed to identify specific risk factors for osteoporosis in patients with AIH and to develop a scoring system that could be used to identify patients with increased risk of osteoporosis.We performed a retrospective cross-sectional study of 211 patients (mean age, 56.8 years; 79.1% women) in Germany with a diagnosis of AIH from 2012 through 2017 and an indication for assessment of bone mineral status. The patients underwent bone mineral density measurements by dual energy X-ray absorptiometry. A subgroup of 99 patients underwent a second measurement. We used logistic regression to identify patient and clinical factors associated with the presence of osteoporosis. We developed a weighted sum score for estimating risk of osteoporosis and tested it in development (n=141) and validation (n=70) sets of patients.According to dual energy X-ray absorptiometry measurements, 15.6% of patients had osteoporosis 42.9% were in the range for osteopenia. The prevalence of osteoporosis in patients 50 years or older was 19.2%. Univariate and logistic regression analyses showed that age older than 54 years, duration of glucocorticoid use >90 months, body mass index <23 kg/m2 and transient elastography values >8 kPA increased risk of osteoporosis 13.8-fold, 6.2-fold, 5.9-fold, and 3.0-fold, respectively. Based on these factors, we developed an index that identified patients at low-, moderate-, and high-risk of osteoporosis with an area under the curve of 0.811. Of the patients with a second osteodensitometry measurement, the rate of bone loss progression ranged from 2.7% after 1 year to 8.4% after 7 years (mean bone loss, 1.2% per year).Almost 20% of patients with AIH older than 50 years have osteoporosis. Older age, duration of corticosteroid use, low body mass index, and liver fibrosis are independent risk factors for bone loss.

» Read more