Incidence of and risk factors for clinical fractures in patients with systemic lupus erythematosus and matched controls: a population-based study in the United Kingdom door Mw. Dr. I.E.M. Bultink, reumatoloog, VUMC
Heeft Cystatine C bij ouderen een toegevoegde waarde bovenop de gekende risic...Cédric De Jaeger
masterproef 4de master geneeskunde:
studie op belfrail-populatie
nagaan voorspellende waarde cystatine c ten op zichte van creatinine naar algemene en cardiovasculaire mortaliteit
Incidence of and risk factors for clinical fractures in patients with systemic lupus erythematosus and matched controls: a population-based study in the United Kingdom door Mw. Dr. I.E.M. Bultink, reumatoloog, VUMC
Heeft Cystatine C bij ouderen een toegevoegde waarde bovenop de gekende risic...Cédric De Jaeger
masterproef 4de master geneeskunde:
studie op belfrail-populatie
nagaan voorspellende waarde cystatine c ten op zichte van creatinine naar algemene en cardiovasculaire mortaliteit
IWO Meeting 1 November 2023 - Stopping with Denosumab and Romosozumab, basic mechanisms and clinical aspects door Prof. dr. S. Ferrari, Geneva, Switzerland. (Engelstalige lezing)
1) DXA scanning is a reliable and low-radiation method to measure bone mineral density (BMD) at the lumbar spine, hip, and wrist to diagnose osteoporosis.
2) DXA can also detect vertebral fractures (VFA) and measure whole body composition, abdominal fat, and aortic calcification.
3) Interpretation of DXA results requires attention to potential variability between devices, accurate placement of regions of interest, and use of appropriate reference data since BMD can be under or overestimated in certain patients.
This document summarizes osteonecrosis of the jaw (ONJ) associated with antiresorptive agents. It defines ONJ and stages its severity. It discusses the pathogenesis of ONJ and risk factors like underlying disease, treatment duration, and dental procedures. Cancer patients on intravenous bisphosphonates have the highest ONJ risk of 1-8% due to higher drug doses and worse oral/general health. Management involves conservative measures like mouthwashes for early stages and surgery with antibiotics for later stages. Discontinuing antiresorptives may help healing but risks fractures. Teriparatide may help healing in some cases but its use in cancer is uncertain. More research is needed on preventing and treating established ON
This systematic review analyzed 895 cases of tumor-induced osteomalacia (TIO) from case reports. TIO is caused by tumors that produce excess fibroblast growth factor 23 (FGF23), which causes hypophosphatemia and osteomalacia. The review found that TIO mostly affects adults aged 40-60 years old, with long diagnostic delays of several years on average. The tumors were located variably but most commonly in the lower limbs or head and neck region. Higher FGF23 levels correlated with larger tumor size. Patients experienced significant bone fragility and fracture rates as high as 60% due to long-term hypophosphatemia. Early tumor detection and removal are important to improve outcomes for
This document discusses real-world evidence on denosumab for osteoporosis treatment and fracture prevention. It summarizes several studies, including one that found denosumab reduced fracture risk by 38% compared to placebo in over 25,000 postmenopausal women. Another study showed good long-term persistence with denosumab therapy in over 800 patients. Additional studies observed that zoledronic acid can prevent bone loss following denosumab discontinuation, and bisphosphonate treatment after denosumab provides protection against new vertebral fractures.
IWO Meeting 16 November 2022 - ASBMR young talent: Silvia Storoni (Amsterdam): Prevalence and Hospital Admissions in Patients With Osteogenesis Imperfecta in The Netherlands: A Nationwide Registry Study
The document appears to be a presentation on highlights from the ASBMR 2021 conference in San Diego. It discusses several topics that were covered at the conference, including fracture risk assessment, the effects of various osteoporosis treatments on bone mineral density, safety issues like osteonecrosis of the jaw and atypical femoral fractures, the role of vitamin D, and applications of artificial intelligence. The entire document is copyrighted by Prof. Dr. Joop van den Bergh.
This document discusses guidelines for medication to prevent fractures in patients using glucocorticoids. It notes that glucocorticoids significantly increase the risk of vertebral and non-vertebral fractures. While effective anti-osteoporosis drugs are available, many glucocorticoid-treated patients remain untreated. The document reviews new guidelines that simplify treatment criteria to improve implementation and outlines recommendations for when to start bone-sparing medications based on patient factors and glucocorticoid dose and duration. The goal is to optimize fracture prevention in glucocorticoid-treated patients.
This document discusses what actions should be taken when a vertebral fracture is discovered incidentally. It notes that vertebral fractures are very common fractures, especially in older individuals, and are often asymptomatic. Having a vertebral fracture significantly increases one's risk for future fractures both in the short and long term. If a vertebral fracture is found incidentally, such as on a CT scan, further investigation is warranted including assessing bone mineral density and checking for underlying bone diseases. Treatment options should also be considered, especially if the individual has low bone density in addition to the vertebral fracture, as this combination confers the highest risk. New automated detection algorithms aim to help identify vertebral fractures on scans to ensure appropriate follow up for individuals.
This document summarizes a cost-effectiveness model of Fracture Liaison Services (FLS) care in the Netherlands. The model found that FLS care would be highly cost-effective, with a cost of €9,076 per quality-adjusted life year gained. Total 5-year costs with FLS would be only 1.7% higher than current costs but would prevent fractures and improve health outcomes. The model can help decision-makers prioritize secondary fracture prevention and allow local payers and FLS to predict costs and benefits of implementation.
More Related Content
More from Stichting Interdisciplinaire Werkgroep Osteoporose
IWO Meeting 1 November 2023 - Stopping with Denosumab and Romosozumab, basic mechanisms and clinical aspects door Prof. dr. S. Ferrari, Geneva, Switzerland. (Engelstalige lezing)
1) DXA scanning is a reliable and low-radiation method to measure bone mineral density (BMD) at the lumbar spine, hip, and wrist to diagnose osteoporosis.
2) DXA can also detect vertebral fractures (VFA) and measure whole body composition, abdominal fat, and aortic calcification.
3) Interpretation of DXA results requires attention to potential variability between devices, accurate placement of regions of interest, and use of appropriate reference data since BMD can be under or overestimated in certain patients.
This document summarizes osteonecrosis of the jaw (ONJ) associated with antiresorptive agents. It defines ONJ and stages its severity. It discusses the pathogenesis of ONJ and risk factors like underlying disease, treatment duration, and dental procedures. Cancer patients on intravenous bisphosphonates have the highest ONJ risk of 1-8% due to higher drug doses and worse oral/general health. Management involves conservative measures like mouthwashes for early stages and surgery with antibiotics for later stages. Discontinuing antiresorptives may help healing but risks fractures. Teriparatide may help healing in some cases but its use in cancer is uncertain. More research is needed on preventing and treating established ON
This systematic review analyzed 895 cases of tumor-induced osteomalacia (TIO) from case reports. TIO is caused by tumors that produce excess fibroblast growth factor 23 (FGF23), which causes hypophosphatemia and osteomalacia. The review found that TIO mostly affects adults aged 40-60 years old, with long diagnostic delays of several years on average. The tumors were located variably but most commonly in the lower limbs or head and neck region. Higher FGF23 levels correlated with larger tumor size. Patients experienced significant bone fragility and fracture rates as high as 60% due to long-term hypophosphatemia. Early tumor detection and removal are important to improve outcomes for
This document discusses real-world evidence on denosumab for osteoporosis treatment and fracture prevention. It summarizes several studies, including one that found denosumab reduced fracture risk by 38% compared to placebo in over 25,000 postmenopausal women. Another study showed good long-term persistence with denosumab therapy in over 800 patients. Additional studies observed that zoledronic acid can prevent bone loss following denosumab discontinuation, and bisphosphonate treatment after denosumab provides protection against new vertebral fractures.
IWO Meeting 16 November 2022 - ASBMR young talent: Silvia Storoni (Amsterdam): Prevalence and Hospital Admissions in Patients With Osteogenesis Imperfecta in The Netherlands: A Nationwide Registry Study
The document appears to be a presentation on highlights from the ASBMR 2021 conference in San Diego. It discusses several topics that were covered at the conference, including fracture risk assessment, the effects of various osteoporosis treatments on bone mineral density, safety issues like osteonecrosis of the jaw and atypical femoral fractures, the role of vitamin D, and applications of artificial intelligence. The entire document is copyrighted by Prof. Dr. Joop van den Bergh.
This document discusses guidelines for medication to prevent fractures in patients using glucocorticoids. It notes that glucocorticoids significantly increase the risk of vertebral and non-vertebral fractures. While effective anti-osteoporosis drugs are available, many glucocorticoid-treated patients remain untreated. The document reviews new guidelines that simplify treatment criteria to improve implementation and outlines recommendations for when to start bone-sparing medications based on patient factors and glucocorticoid dose and duration. The goal is to optimize fracture prevention in glucocorticoid-treated patients.
This document discusses what actions should be taken when a vertebral fracture is discovered incidentally. It notes that vertebral fractures are very common fractures, especially in older individuals, and are often asymptomatic. Having a vertebral fracture significantly increases one's risk for future fractures both in the short and long term. If a vertebral fracture is found incidentally, such as on a CT scan, further investigation is warranted including assessing bone mineral density and checking for underlying bone diseases. Treatment options should also be considered, especially if the individual has low bone density in addition to the vertebral fracture, as this combination confers the highest risk. New automated detection algorithms aim to help identify vertebral fractures on scans to ensure appropriate follow up for individuals.
This document summarizes a cost-effectiveness model of Fracture Liaison Services (FLS) care in the Netherlands. The model found that FLS care would be highly cost-effective, with a cost of €9,076 per quality-adjusted life year gained. Total 5-year costs with FLS would be only 1.7% higher than current costs but would prevent fractures and improve health outcomes. The model can help decision-makers prioritize secondary fracture prevention and allow local payers and FLS to predict costs and benefits of implementation.
More from Stichting Interdisciplinaire Werkgroep Osteoporose (20)
12. Traditionele factoren
Menopauze
Meeste studies: alleen premenopauzale
vrouwen of invloed menopauzale toestand niet
vermeld
Postmenopauze risicofactor voor lage BMD
Kipen ’97: heup
Bhattoa ’02
Hartkamp* ’04: LWK
Bultink* ’05: LWK en heup
Almehed ’07: LWK en/of heup
* = Nederlandse studie
13. Traditionele factoren
Ethniciteit: zeer weinig studies
Kaukasisch ras als risicofactor
USA (n=92): BMD heup Lakshminarayanan ‘01
UK (n=242): BMD lager bij niet-negroïden
Yee, ’05
Negroide ras als risicofactor
USA (n=298): BMD LWK lager bij negroïden
Lee, ‘07
14. Traditionele factoren
5 Aziatische studies:
prevalentie osteoporose (1,4 – 22%)
lager dan in kaukasische studies
Li ’98: China
Uaratanawong ’03: Thailand
Chong ’07: Maleisië
Li ’09: China
Furukawa ’09: Japan
16. Traditionele factoren
Roken
In meeste studies niet onderzocht
(Nog) geen bewezen RF bij SLE
A’damse SLE cohort: 22% rookt
Alcohol
Significante RF in één studie bij Chineze
mannen met SLE Mok ’08
17. Traditionele factoren
Eerdere osteoporotische fractuur
In meeste studies niet onderzocht
Tot nu toe geen bewezen RF bij SLE
Belaste familieanamnese
Slechts in 4 studies onderzocht
Tot nu toe geen bewezen RF bij SLE
20. Inflammatie
Laag C4: associatie met lage BMD Petri, ’95
Ziekteactiviteit:
geen associatie met BMD aangetoond
Echter, overwegend cross-sectionele studies en
geen seriële scoring van ziekteactiviteit in
relatie tot BMD verricht
Ziekteduur: discrepante resultaten
21. Inflammatie
Orgaanschade:
Hogere SLICC/ACR damage index: associatie
met lagere BMD
Becker ’01, Lakshminarayanan ’01, Pineau ’04, Lee ’06, Almehed ’07,
Mendoza-Pinto ’09
“Damage is a predictor of further damage”
BMD en HVZ:
Associatie lage BMD heup met carotis plaques
Associatie lage BMD LWK met coronair calcificaties
Ramsey-Goldman, Arthritis Rheum ’01
22. Inflammatie
Nierinsufficiëntie
Slechts in één studie hoog serum creatinine
geassocieerd met lage BMD LWK en radius
(163 Zweedse vrouwen, mediane leeftijd 47 jr)
Almehed, Rheumatology ‘07
Verklaring: verbeterde therapie SLE-nefritis?
SLE cohort A’dam: • 4% creat.klaring < 40 ml/min
• 1/180 patiënten dialyse
34. Medicatie: GC
Discrepante resultaten
Associatie tussen GC gebruik en lage BMD LWK en/of heup?
JA NEE
Cross-sectionele studies (25) 12 13
Longitudinale studies (5) 3 2
Longitudinale studies
* 4 kleine studies (n≤ 36), follow-up duur ≤ 3 jaar
* Recente studie A’dam: n=81, follow-up 5,7 jaar
35. Longitudinale studie naar BMD bij SLE
N = 81
Vumc
Demografische parameters
Ziektegeassocieerde parameters
Ca-intake, UV-expositie, lichaamsbeweging, BMI
Lab: 25(OH)D, nierfunctie
Ziekteactiviteitsscore
Medicatie
DEXA LWK en heup op T=0 en na gem. 5,7 jr
44. Symptomatische fracturen bij SLE
5 studies
1 gecontroleerde studie
USA, n=702
Symptomatische fracturen sinds diagnose SLE
Resultaten:
Incidentie bij vrouwen met SLE 5x verhoogd
10,4% van symptomatische fracturen:
wervelfractuur
Ramsey-Goldman, Arthritis Rheum ’99
45. Symptomatische fracturen bij SLE
studie populatie % met
fractuur
risicofactoren
Petri (’95) 407 6,0 cum en max CS dosis
leeftijd
kalkarm skelet (X-ray)
postmenopauze
avasculaire necrose
Ramsey-Goldman (’99) 702 12,3 duur CS gebruik
leeftijd bij diagnose
Zonana (’00) 539 4,4
(bij OPO)
cum CS dosis
MP iv (trend)
Yee (’05) 242 9,1 leeftijd
lage BMD
Lee (’07) 304 12,5 lage BMD
ziekteduur
46. Prevalentie wervelfracturen bij SLE
4 studies
Geen gecontroleerde studies
Nederlandse studie
N=90, 90% vrouw, gem 41 jr, 77% kaukasisch
Semi-kwantitatieve scoring volgens Genant
39% osteopenie, 4% osteoporose (LWK en/of heup)
20% ≥ 1 wervelfractuur
7% ≥ 2 wervelfracturen
Bultink, Arthritis Rheum ’05
47. Prevalentie wervelfracturen bij SLE
studie populatie gem. leeftijd % met
fractuur
risicofactoren
Bultink, NL
(’05)
90 SLE 41 20 MP iv man
Borba, Bra
(’05)
70 SLE 32 21,4 lage BMD ->
aantal ##
Mendoza-
Pinto, Mex
(’09)
210 SLE 43 26,1 leeftijd
lage BMD heup
Li, Hong Kong
(’09)
152 SLE 48 20,4 leeftijd
lage BMD LWK
hoge BMI
Ørstavik, N
(’03)
Gezonde
vrouwen
63 15
48. Conclusies 1
1. Hoge prevalentie osteopenie/osteoporose bij
(relatief jonge) SLE patiënten
2. Osteoporose bij SLE is multifactorieel bepaald
(traditionele factoren, inflammatie, metabole
factoren, medicatie)
3. GC:prednison > 7,5 mg/dag significant BMD
verlies LWK in longitudinale studies
53. Osteoporose gerelateerde QIs
Toepassing in 2 SLE cohorten
Stanford, USA; n=127
QI I (BMD) 74%
QI II (Ca/D) 58%
QI III (anti-osteoporose medicatie) 56%
Boston, USA; n=200
QI I (BMD) 59%
QI II (Ca/D) 62%
QI III (anti-osteoporose medicatie) 86%
Schmajuk, Arthritis Care Res ’10
Demas, Semin Artritis Rheum ‘10
54. Diagnostiek
Bij SLE speciale aandacht voor
UV intolerantie/sunblocker gebruik
Premature menopauze
Nierfunctie
Vit D serumspiegel
55. Therapie
Therapie
A. (Leef)adviezen
Calciumintake
Lichaamsbeweging
(A’damse cohort: 73% < 3x /week 30 min)
Niet roken (A’damse cohort: 22% rookt)
Lichaamsgewicht
Premature menopauze melden
B. Medicatie
Calcium- en vitamine D suppletie
Op indicatie: anti-osteoporosemedicatie (orale
bisfosfonaten, zoledronaat, HRT, strontiumranelaat)
56. Valkuilen/beperkingen
Meestal jonge patiënten
Onderschatting GC-gebruik door artsen
82% ooit gebruikt; gem. 4,6 jaar (A’damse cohort)
54% actueel gebruik
22% MP iv gebruikt
Vit D deficiëntie (soms ondanks suppletie)
Premature menopauze (11%)
Polyfarmacie
Zwangerschapswens: c.i. bisfosfonaten
Meestal premenopauzaal: effectiviteit en
veiligheid van langdurig bisfosfonaten?
1,4% bij jonge (32 jr gem), premenopauzale Thaise patienten, 68% in subgroep van 32 CS-gebruikende, oudere, postmenopauzale Bulgaarse vrouwen met ZD 13 jaar.