RESUMO
Hand osteoarthritis is the most common joint condition and is associated with significant morbidity. It is of paramount importance that patients are thoroughly assessed and examined when complaining of hand stiffness, pain, deformity or disability and that the patient's concerns and expectations are addressed by the healthcare professional. In 2019 the American College of Rheumatology and Arthritis Foundation (ACR/AF) produced guidelines which included recommendations for the treatment of hand osteoarthritis. An ESCEO expert working group (including patients) was convened and composed this paper with the aim to assess whether these guidelines were appropriate for the treatment of hand osteoarthritis therapy in Europe and whether they met with the ESCEO patient-centered approach. Indeed, patients are the key stakeholders in healthcare and eliciting the patient's preference is vital in the context of an individual consultation but also for informing research and policy-making. The patients involved in this working group emphasised the often-neglected area of aesthetic changes in hand osteoarthritis, importance of developing pharmacological therapies which can alleviate pain and disability and the need of the freedom to choose which approach (out of pharmacological, surgical or non-pharmacological) they wished to pursue. Following robust appraisal, it was recommended that the ACR/AF guidelines were suitable for a European context (as described within the body of the manuscript) and it was emphasised that patient preferences are key to the success of individual consultations, future research and future policy-making.
Assuntos
Osteoartrite do Joelho , Europa (Continente) , Medicina Baseada em Evidências , Humanos , Osteoartrite do Joelho/terapia , Assistência Centrada no Paciente , Encaminhamento e ConsultaRESUMO
Romosozumab is a monoclonal antibody against sclerostin. Its dual effect on bone is to increase formation and decrease resorption. Sub-cutaneous injections of romosozumab are administered monthly for one year and must be relayed with a bone resorption inhibitor. Romosozumab followed by denosumab is associated with high increase of bone mineral density and decrease of fragility fractures. Gain of bone mineral density and reduction of fragility fractures are more important with romosozumab as compared with alendronate. The increase in bone mineral density is higher with romosozumab as compared to teriparatide in patients previously treated with alendronate. The use of romosozumab (Evenity) is admitted for patients with high risk of fractures but without serious vascular events.
Le romosozumab est un anticorps monoclonal dirigé contre la sclérostine, dont le double effet osseux est de stimuler la formation et diminuer la résorption. Il s'administre en injections sous-cutanées mensuelles pendant une année et il doit être relayé par un traitement inhibiteur de la résorption osseuse. La séquence romosozumab puis dénosumab est associée à des gains densitométriques et à une réduction des fractures de fragilité de grande amplitude. La réponse densitométrique et l'effet antifracturaire sont plus marqués sous romosozumab que sous alendronate. L'augmentation de la densité minérale osseuse est plus importante sous romosozumab que sous tériparatide après traitement préalable par alendronate. Le romosozumab (Evenity) est approuvé pour des patients avec un risque élevé de fracture en l'absence de complications vasculaires sévères.
Assuntos
Conservadores da Densidade Óssea , Osteoporose , Alendronato , Anticorpos Monoclonais , Densidade Óssea , Humanos , Osteoporose/tratamento farmacológicoRESUMO
New recommendations from the Swiss Association against Osteoporosis (SVGO) concerning fracture risk stratification and treatment delineate two new risk categoriesâ : very high risk (FRAX 10-years probability of fracture at least 20â % above the usual intervention threshold) and imminent risk (major osteoporotic fracture in the last 2 years). In these patients, parenteral therapies are recommended first. Among them, romosozumab is now available in Switzerland and is indicated for 1 year in absence of cardiovascular contra-indications, followed by an anti-resorptive. Regarding denosumab, several studies indicate that post-treatment bone loss may be, at least partially, prevented by zoledronate. Finally, monitoring BMD changes and the T-score reached on any therapy could be used as an indicator of anti-fracture efficacy.
Les nouvelles directives de l'Association suisse contre l'ostéoporose proposent deux nouvelles catégories dans la stratification du risque fracturaire et du traitementâ : très haut risque (FRAX au moins 20â % au-dessus du seuil d'intervention pour l'âge) et risque imminent (fracture ostéoporotique majeure au cours des 2 dernières années). Chez ces patient·e·s, les thérapies parentérales sont indiquées en première intention. Parmi celles-ci, le romosozumab est maintenant disponible en Suisse et est indiqué pour 1 an en l'absence de contre-indication cardiovasculaire, suivi d'un antirésorptif. Concernant le dénosumab, plusieurs études ont démontré que la perte osseuse à l'arrêt peut être, au moins partiellement, prévenue par l'acide zolédronique. Finalement, le score-T atteint sous thérapie pourrait être un indicateur clinique de l'effet antifracturaire.
Assuntos
Anticorpos Monoclonais/uso terapêutico , Osteoporose/tratamento farmacológico , Densidade Óssea/efeitos dos fármacos , Denosumab/uso terapêutico , Aprovação de Drogas , Humanos , Infusões Parenterais , Fraturas por Osteoporose/prevenção & controle , Suíça , Ácido Zoledrônico/uso terapêuticoRESUMO
Irrespective of their age, patients with recent fragility fracture have an increased risk of recurrenceâ : this is the imminent fracture risk of multiple origins. As well the vertebral than the non-vertebral fractures are equally predictive of an increased and early fracture risk. Therefore, a fragility fracture is a strong signal for the clinicians to introduce a treatment against osteoporosis. Especially since most of the treatment have been shown to reduce quickly the incidence of fractures. To target easily patients with the highest risk of re-fractures would allow to improve our efficacy.
Indépendamment de leur âge, les patients qui ont récemment présenté une fracture de fragilité sont à risque élevé de récidiveâ : c'est le risque imminent de fractures dont les causes sont multiples. Les fractures récentes, qu'elles soient vertébrales ou non vertébrales, sont prédictives d'un risque accru et précoce de récurrence. De ce fait, la survenue d'une fracture de fragilité est un signal fort pour le clinicien pour introduire un traitement anti-ostéoporotique. D'autant plus que la plupart des traitements disponibles sont capables de réduire précocement les fractures. Cibler aisément les patients les plus à risque de (re)fractures permettrait ainsi d'augmenter l'efficacité de notre prise en charge.
Assuntos
Fraturas por Osteoporose , Fraturas da Coluna Vertebral , Densidade Óssea , Humanos , Incidência , Fraturas por Osteoporose/epidemiologia , Fraturas por Osteoporose/prevenção & controle , Fatores de Risco , Fraturas da Coluna Vertebral/epidemiologia , Fraturas da Coluna Vertebral/prevenção & controleRESUMO
Denosumab discontinuation is associated with a severe rebound effect combining elevation of bone remodeling markers for two years and loss of the gained bone density. In the absence of a potent bisphosphonate prescription at denosumab discontinuation, multiple vertebral fractures are frequent. The median number of vertebral fractures is 5, within 7 to 20 months (median 11) after the last denosumab injection. A potent bisphosphonate prescribed at denosumab discontinuation may reduce this risk. This strategy requires close monitoring of bone remodeling markers and adjustment of treatment if bone remodeling is not controlled.
L'arrêt du dénosumab est associé à un effet rebond sévère associant élévation des marqueurs du remodelage osseux pour deux ans et perte du gain de densité osseuse. A l'arrêt du dénosumab, en l'absence de prescription d'un puissant bisphosphonate, la fréquence des fractures vertébrales multiples est élevée. Le nombre médian de fractures vertébrales est de 5 dans les 7 à 20 mois (médiane 11) suivant la dernière injection de dénosumab. Un bisphosphonate puissant prescrit à l'arrêt du traitement de dénosumab pourrait réduire ce risque. Cette stratégie nécessite un suivi serré des marqueurs du remodelage osseux et un ajustement du traitement si le remodelage osseux n'est pas suffisamment contrôlé.
Assuntos
Conservadores da Densidade Óssea , Denosumab , Osteoporose Pós-Menopausa , Fraturas da Coluna Vertebral , Conservadores da Densidade Óssea/administração & dosagem , Conservadores da Densidade Óssea/efeitos adversos , Remodelação Óssea , Denosumab/administração & dosagem , Denosumab/efeitos adversos , Difosfonatos , Humanos , Osteoporose Pós-Menopausa/tratamento farmacológico , Fraturas da Coluna Vertebral/induzido quimicamente , Fraturas da Coluna Vertebral/prevenção & controleRESUMO
The risk for a second fracture within two years after a first one is high. Ten years denosumab treatment show favorable results with a risk of early vertebral fractures in patients with prevalent vertebral fractures when treatment is stopped. Teriparatide is more effective than risedronate to prevent vertebral and clinical fractures in high risk patients. Romosozumab acts as an anabolic agent in osteoporosis. Atypical femoral fractures associated with bisphosphonate treatment could be more frequent in patients with particular anatomical features. Management of osteoporosis treatment depends on the drug which is used and on the risk of fracture of the patient.
Le risque de deuxième fracture dans les deux ans qui suivent un premier épisode est élevé. Les résultats de dix ans continus de dénosumab sont favorables, mais son arrêt expose au risque de fractures vertébrales précoces, surtout en cas de fractures vertébrales prévalentes. Le tériparatide est plus efficace que le risédronate pour prévenir les fractures vertébrales et cliniques chez les patientes à très haut risque. Le romosozumab confirme son intérêt comme agent anabolique dans le traitement de l'ostéoporose. Les fractures fémorales atypiques sous bisphosphonates pourraient être favorisées par des caractéristiques anatomiques. L'algorithme décisionnel pour la prise en charge de l'ostéoporose dépend de la nature du traitement et du risque de fracture du patient.
Assuntos
Conservadores da Densidade Óssea , Osteoporose , Densidade Óssea , Conservadores da Densidade Óssea/uso terapêutico , Denosumab/uso terapêutico , Humanos , Osteoporose/tratamento farmacológico , Teriparatida/uso terapêuticoRESUMO
After one year of treatment with denosumab, the incidence of fracture is lower in patients previously treated one year with romosozumab as compared with placebo. Cessation of denosumab injections is followed by a rebound of bone resorption, a decrease of bone mineral density and increased risk of multiple vertebral fractures. For safety reasons, odanacatib, an inhibitor of cathepsine K and consecutively of bone resorption will not be available. Abaloparatide, a PTHrp(Parathormon related protein) analog, decreases the incidence of vertebral and non vertebral fractures. In patients with diabetes, the incidence of fractures is increased mainly due to alterations quality of bone.
L'incidence des fractures est moindre après un an de traitement par dénosumab chez des patients préalablement traités par romosozumab pendant une année en comparaison de ceux initialement sous placebo. L'arrêt du dénosumab est suivi d'un rebond de la résorption osseuse avec diminution des densités osseuses et risque de survenue de fractures vertébrales multiples. Pour des raisons de sécurité d'emploi, l'odanacatib, un antirésorbeur inhibiteur de la cathepsine K, ne sera pas commercialisé. L'abaloparatide, un analogue de la PTHrp (protéine apparentée à la parathormone), réduit l'incidence des fractures vertébrales et non vertébrales. Celle des fractures de fragilité est augmentée chez les patients diabétiques en relation avec des altérations de la qualité osseuse.
Assuntos
Osteoporose , Anticorpos Monoclonais/uso terapêutico , Densidade Óssea/efeitos dos fármacos , Conservadores da Densidade Óssea/uso terapêutico , Denosumab/uso terapêutico , Complicações do Diabetes/diagnóstico , Complicações do Diabetes/tratamento farmacológico , Humanos , Osteoporose/tratamento farmacológico , Osteoporose/etiologiaRESUMO
Estrogen replacement therapy, selective modulators of the estrogen receptor (SERMs), bisphophonates and denosumab are antiresorptive therapies which can be used for several years. Teriparatide is still the only bone forming agent available, its use is limited to 24 months. Except the absence of new fragility fractures, there is no well defined target in the treatment of osteoporosis. Nevertheless persistence of high fracture risk (prevalent fractures and/or low BMD) on therapy indicates to maintain or intensify the treatment. On the contrary, if fracture risk is low, a « therapeutic window ¼ could be considered after treatment with bisphosphonates, whereas after denosumab a short course of another treatment may be necessary.
L'Åstrogénothérapie substitutive, les modulateurs sélectifs du récepteur aux Åstrogènes (SERM), les bisphosphonates et le dénosumab sont des inhibiteurs de la résorption osseuse qui peuvent être utilisés plusieurs années. Le tériparatide est le seul traitement ostéoformateur et son utilisation est limitée à 24 mois. Hormis l'absence de nouvelles fractures de fragilité, il n'y a pas de cible thérapeutique définie dans le traitement de l'ostéoporose. Néanmoins, la persistance sous traitement d'un haut risque de fracture (fractures prévalentes et/ou ostéodensitométrie basse), est une indication à poursuivre, voire intensifier la thérapie. Si le risque de fracture est bas, au contraire, une « fenêtre thérapeutique ¼ est envisagée pour les traitements dont la durée d'action est plus longue que leur période d'administration (bisphosphonates). Pour le dénosumab, un relais thérapeutique de courte durée est nécessaire.
Assuntos
Conservadores da Densidade Óssea/administração & dosagem , Osteoporose/tratamento farmacológico , Fraturas por Osteoporose/prevenção & controle , Densidade Óssea , Terapia de Reposição de Estrogênios/métodos , Humanos , Osteoporose/complicações , Moduladores Seletivos de Receptor Estrogênico/administração & dosagem , Teriparatida/administração & dosagem , Fatores de TempoRESUMO
Calcium intake shows a small impact on bone mineral density and fracture risk. Denosumab is a more potent inhibitor of bone resorption than zoledronate. Abaloparatide, PTHrP analog, increases bone mineral density and decreases fracture incidence. Teriparatide could be delivered via a transdermic device. Romosozumab and odanacatib improve calculated bone strength. Sequential or combined treatments with denosumab and teriparatide could be of interest, but not denosumab followed by teriparatide. Fibrous dysplasia, Paget disease and hypophosphatasia are updated, as well as atypical femoral fracture and osteonecrosis of the jaw.
Assuntos
Densidade Óssea/efeitos dos fármacos , Doenças Ósseas/tratamento farmacológico , Fraturas Ósseas/prevenção & controle , Conservadores da Densidade Óssea/uso terapêutico , Doenças Ósseas/fisiopatologia , Cálcio/administração & dosagem , HumanosRESUMO
Bone events related to bariatric surgery remain controversial. Denosumab, used in osteoporosis treatment, is safe and efficient. Romosozumab, an antibody raised against sclerostin, is a promising bone anabolic agent. Odanacatib, a cathepsin-K inhibitor, decreases bone resorption and reduces osteoporotic fracture risk. Denosumab, as bone resorption inhibitor, and Teriparatide, as anabolic agent, have been tested together in patients with osteoporosis. Calcium supplements and cardiovascular risk are still debated. Drug holiday, after long-term treatment with bisphosphonates, is not associated with an increased fracture rate in patients with moderate risk.
Assuntos
Osteoporose/tratamento farmacológico , Anticorpos Monoclonais/uso terapêutico , Anticorpos Monoclonais Humanizados/uso terapêutico , Cirurgia Bariátrica/efeitos adversos , Compostos de Bifenilo/uso terapêutico , Denosumab , Humanos , Osteoporose/etiologiaRESUMO
The quality of the management of patients with osteoporosis varies by country. The recommendations of the Swiss Association against osteoporosis propose intervention thresholds based on the results of the FRAX tool. Despite increasing number of observational studies with several hundred thousands of patients, it is not possible to conclude to a clear increased risk of cardiovascular disease with calcium intakes. A persistent effect of zoledronic acid is observed even after one single injection. There is no increased fracture risk within 7 months following Denosumab treatment cessation.
Assuntos
Osteoporose/terapia , Anticorpos Monoclonais Humanizados/uso terapêutico , Conservadores da Densidade Óssea/uso terapêutico , Cálcio/uso terapêutico , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Denosumab , Difosfonatos/uso terapêutico , Fraturas Ósseas/induzido quimicamente , Fraturas Ósseas/epidemiologia , Humanos , Imidazóis/uso terapêutico , Osteoporose/epidemiologia , Osteoporose/etiologia , Raquitismo/complicações , Raquitismo/epidemiologia , Raquitismo/terapia , Fatores de Risco , Ácido ZoledrônicoRESUMO
In traumatology, non-steroidal anti-inflammatory drugs (NSAIDs) are widely used, due to their efficacy in controlling pain and safety profile. Nonetheless, experimental and retrospective studies about the use of NSAIDs in traumatology raise the question about a possible negative influence on bone remodeling through inhibition of prostaglandin synthesis. The results from these studies must be interpreted with caution, as bone repair can be influenced by several parameters. When used in the case of sprains or tendinitis, unwanted side effects of NSAIDs seem to be limited; on the other hand, benefits in terms of antalgic effect are less clear. We have conducted a review of the literature aimed to suggest practical solutions for the use of NSAIDs in traumatology.
Assuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Uso de Medicamentos , Ferimentos e Lesões/tratamento farmacológico , Anti-Inflamatórios não Esteroides/efeitos adversos , Osso e Ossos/lesões , Fraturas Ósseas/tratamento farmacológico , Humanos , Entorses e Distensões/tratamento farmacológico , Tendinopatia/tratamento farmacológicoRESUMO
Glucocorticoid excess, either from exogenous exposure or through endogenous overproduction, is a common cause of secondary osteoporosis. We report a 52-year-old woman presenting with multiple stress fractures of the lower extremities, despite various osteoporosis therapeutic regimens. Investigations led to the diagnosis of hypercortisolism of pituitary origin. Pituitary surgery was unsuccessful, justifying a treatment of ketoconazole. In the absence of densitometric osteoporosis, assessment of bone microstructure using high resolution peripheral quantitative computed tomography revealed alterations of both the cortical and trabecular compartments. This case illustrates that hypercortisolism may cause bone fragility in the absence of marked changes in areal bone mineral density.
RESUMO
Osteoporosis is a disease characterized by an increased fragility of bone due to micro and macro structural changes of bone tissue and as a consequence a higher risk of fractures. Both women and men can be concerned by the problem, but in men a secondary origin is generally found with less fractures than in women, but with more morbidity. Both the diagnosis and the therapy are relatively similar in men as compared to women with postmenopausal osteoporosis. This paper is aimed at critically discussing the various differences in osteoporosis between men and women starting with some epidemiological considerations and ending with the therapeutical aspects.
Assuntos
Fraturas Espontâneas/epidemiologia , Fraturas Espontâneas/prevenção & controle , Saúde do Homem , Osteoporose/tratamento farmacológico , Osteoporose/epidemiologia , Osteoporose/prevenção & controle , Feminino , Humanos , Masculino , Prevalência , Fatores de RiscoRESUMO
Osteoporosis is the most common chronic metabolic bone disease, known to be underdiagnosed and undertreated in parts of the Swiss population. Due to expected rise in new fragility fractures, adequate awareness of associated risk factors and diagnostic and therapeutic options will be essential for the management of osteoporosis. We therefore explored these aspects in a nationwide survey of Swiss specialists and their patients. A total of 262 physician questionnaires and 9065 patient questionnaires were analyzed, mainly from general practitioners (64.9%), followed by rheumatologists (16.8%), gynecologists (12.2%), and endocrinologists (6.1%). Around 20% of patients were under medication and/or had a medical condition increasing the risk of osteoporosis. Further risk factors, such as low consumption of calcium-rich foods, smoking, elevated alcohol intake, and insufficient physical activity, were present across regions and medical fields. 53.9% of patients did not take calcium/vitamin D supplements; 3.5% reported having fragility fractures, and 7.3% received treatment for osteoporosis. Only 38.5% of surveyed patients knew of the chronic nature of osteoporosis, indicating rather low awareness in this population. Despite generally perceived relevance of osteoporosis for daily practice, aspects of its prevention and management varied across regions and medical fields. Raising awareness among patients and physicians will be vital for addressing osteoporosis on a national scale.
RESUMO
Atypical femoral fractures (AFFs) occurring during the course of osteoporosis treatment usually lead to discontinuation of anti-resorptive (AR) drugs. However, the risk of fracture after an AFF is unknown. We conducted a follow-up study of patients with AFF matched 1:3 for age and gender with patients with a peripheral major osteoporotic fracture (pMOF), in the setting of a fracture liaison service, to investigate the incidence of subsequent low-trauma fractures. Fifty-five patients with AFF (95% women, age [mean ± standard deviation] 75 ± 10 years, 89% exposed to AR drugs), followed for 6.2 ± 3.7 years, were compared to 165 matched controls with a pMOF (hip 85%) followed for 4.3 ± 2.6 years. During the follow-up, 38% of patients in the AFF group and 16% in the pMOF group received AR therapies. Continuation of AR drugs after an AFF was associated with contralateral AFF in 27% of subjects. The risks of new low-trauma, major osteoporotic and imminent (within 2 years) fractures, were similar between the two groups: incidence rate ratio (95% confidence interval [CI]) of subsequent fracture following AFF relative to pMOF, 1.30 (95% CI, 0.82-2.04), 1.28 (95% CI, 0.74-2.15), and 1.11 (95% CI, 0.54-2.15), respectively. Moreover, the risk of sustaining multiple fractures per participant was significantly increased among patients with AFF compared to pMOF (hazard ratio 1.48 [95% CI, 1.00-2.19]; p = 0.049). When taking mortality into account, the risk of subsequent fractures tended to be higher in the AFF group (sub-hazard ratio 1.42 [95% CI, 0.95-2.12]). In conclusion, patients who sustained an AFF are at high risk of subsequent fragility fractures, at least equal or even greater to the risk observed after a pMOF. However, continuation of AR drugs increases the risk of contralateral AFF. Therefore, optimal modalities for secondary fracture prevention after AFF require further evaluation. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
Assuntos
Conservadores da Densidade Óssea , Fraturas do Fêmur , Fraturas por Osteoporose , Idoso , Idoso de 80 Anos ou mais , Conservadores da Densidade Óssea/uso terapêutico , Difosfonatos/efeitos adversos , Feminino , Fraturas do Fêmur/induzido quimicamente , Fraturas do Fêmur/tratamento farmacológico , Fraturas do Fêmur/epidemiologia , Seguimentos , Humanos , Incidência , Masculino , Fraturas por Osteoporose/tratamento farmacológico , Estudos RetrospectivosRESUMO
Calcium supplements should be used according to the dietary intakes. Daily vitamin D supplements have beneficial on bone and extraskeletal effects. Denosumab is registered in Switzerland for the treatment of postmenopausal osteoporosis and to prevent bone loss induced by sex hormone deprivation therapies in men and women. Zoledronate has a long-term efficacy on bone resorption in postmenopausal women and prevents bone loss induced by sex hormone deprivation therapies in both sexes. Teriparatide exerts beneficial effects on maxillary bone. Odanacatib decreases bone resorption and increases bone mineral density. Cinacalcet could be used as long-term treatment in case of hyperparathyroidism. Adverse events associated with the use of bisphosphonate are still under discussion. Strontium ranelate will not be introduced in Switzerland.