Fragility fractures and prescriptions of medications for osteoporosis in patients with polymyalgia rheumatica: results from the PMR Cohort Study

Abstract Objectives Polymyalgia rheumatica (PMR) is a common indication for long-term glucocorticoid treatment leading to an increased risk of osteoporosis and fragility fractures. Guidelines recommend calcium and vitamin D for all patients, as well as anti-resorptive agents for high-risk patients. This study aimed to investigate falls and fragility fracture history and use of medications for osteoporosis in a PMR cohort. Methods 652 people with incident PMR responded to a postal survey. Self-reported data on falls, fragility fracture history and medication were collected at baseline. Follow up data on fragility fractures (hip, wrist, spine) and falls were collected at 12 and 24 months. Logistic regression was used to assess the association between baseline characteristics and fractures. Results Fewer than 50% of respondents received osteoporosis treatments, including supplements. 112 (17.2%) participants reported a fragility fracture at baseline, 72 participants reported a fracture at 12 months, whilst 62 reported a fracture at 24-months. Baseline history of falls was most strongly associated with fracture at 12 (OR 2.35; 95% CI 1.35, 4.12) and 24 months (1.91; 1.05, 3.49) when unadjusted for previous fractures. Conclusions Fracture reporting is common in people with PMR. To improve fracture prevention, falls assessment and interventions need to be considered. History of falls could help inform prescribing decisions around medications for osteoporosis. Future research should consider both pharmacological and non-pharmacological approaches to reducing fracture risk.

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O03 Prevalence of fragility fractures and medication prescription for osteoporosis in patients with polymyalgia rheumatica: results from the PMR Cohort Study

Rheumatology ◽

10.1093/rheumatology/keab246.002 ◽

2021 ◽

Vol 60 (Supplement_1) ◽

Author(s):

Balamrit Singh Sokhal ◽

Samantha L Hider ◽

Zoe Paskins ◽

Christian D Mallen ◽

Sara Muller

Keyword(s):

Vitamin D ◽

Fragility Fracture ◽

Polymyalgia Rheumatica ◽

Fragility Fractures ◽

Term Treatment ◽

Baseline Survey ◽

Adherence To Guidelines ◽

Increased Risk ◽

Long Term Treatment

Abstract Background/Aims Polymyalgia rheumatica (PMR) is one of the commonest indications for long term glucocorticoid (GC) use, leading to an increased risk of osteoporosis and fragility fractures. Clinical guidelines recommend prescribing medication including vitamin D, calcium and anti-resorptives, such as bisphosphonates. The aim of this study was to examine the association of reported falls and prescriptions of medications for osteoporosis with future fragility fractures in a cohort of people with PMR. Methods 652 people with an incident diagnosis of PMR responded to a baseline survey between June 2012 and June 2014. This included data on general health, sociodemographics, history of falls and medication. Data on fractures and prescriptions were collected at 12 and 24 months. Fragility fractures were defined as fractures of the hip, wrist or spine. Logistic regression models were used to assess the association between baseline characteristics and fractures at 12 and 24 months. Analysis was conducted unadjusted and adjusted for age, gender, reported medication use and falls history. Results 112 (17.2%) baseline respondents reported a previous fragility fracture. 60 (83.3%) of the 72 respondents who reported a fragility fracture between baseline and month 12 also reported a fragility fracture at baseline. 49 (79.1%) of the 60 respondents who reported a fragility fracture at between the month 12 and 24 also reported a fragility fracture at baseline. Falls before baseline was the most significant predictor of fragility fracture at 12 (OR 2.35 95% CI 1.35-4.12) and 24 (OR 1.91 95% CI 1.05-3.49) months. Fewer than 50% of respondents were ever prescribed treatment for osteoporosis. Being prescribed treatment for osteoporosis was associated with a reduced incidence of fragility fractures at 24 months (adjusted OR 0.28 95% CI 0.10-0.80), but an increased incidence at 12 months (adjusted OR 2.10 95% CI (1.3-3.48). Calcium and vitamin D prescription, gender and age were not significantly associated with fracture outcome. Conclusion Despite guidelines, fewer than 50% of patients were prescribed medications for osteoporosis. This data highlights the risks of fractures in PMR patients who have experienced previous falls. Over a period of two years, medication for osteoporosis was significantly protective, hence more needs to be done to encourage adherence to guidelines. Further studies need to address reasons for non-adherence to guidelines and the effects of long-term treatment. Disclosure B. Sokhal: None. S.L. Hider: None. Z. Paskins: None. C.D. Mallen: None. S. Muller: None.

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Systematic approaches to fragility fracture prevention

Osteologie/Osteology ◽

10.1055/s-0037-1620030 ◽

2014 ◽

Vol 23 (01) ◽

pp. 39-44

Author(s):

D. B. Lee ◽

P. J. Mitchell

Keyword(s):

Fragility Fracture ◽

National Policy ◽

Fragility Fractures ◽

Fracture Prevention ◽

The United States ◽

Fracture Liaison Service ◽

Reimbursement Mechanisms ◽

Future Fracture ◽

National Coalition ◽

Fracture Liaison

SummaryIndividuals who have suffered fractures caused by osteoporosis – also known as fragility fractures – are the most readily identifiable group at high risk of suffering future fractures. Globally, the majority of these individuals do not receive the secondary preventive care that they need. The Fracture Liaison Service model (FLS) has been developed to ensure that fragility fracture patients are reliably identified, investigated for future fracture and falls risk, and initiated on treatment in accordance with national clinical guidelines. FLS have been successfully established in Asia, Europe, Latin America, North America and Oceania, and their widespread implementation is endorsed by leading national and international osteoporosis organisations. Multi-sector coalitions have expedited inclusion of FLS into national policy and reimbursement mechanisms. The largest national coalition, the National Bone Health Alliance (NBHA) in the United States, provides an exemplar of achieving participation and consensus across sectors. Initiatives developed by NBHA could serve to inform activities of new and emerging coalitions in other countries.

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No Sex Differences in Risk for Lower-Extremity Musculoskeletal Injury in Concussed Amateur Rugby Players

Neurology ◽

10.1212/01.wnl.0000719980.86372.7f ◽

2020 ◽

Vol 95 (20 Supplement 1) ◽

pp. S12.1-S12

Author(s):

Katelyn Costantini ◽

Katie Hunzinger ◽

Charles Buz Swanik ◽

Thomas A. Buckley

Keyword(s):

Sex Differences ◽

Lower Extremity ◽

Collegiate Athletes ◽

Musculoskeletal Injury ◽

Future Research ◽

Ratio Test ◽

Male And Female ◽

Increased Risk ◽

History Of ◽

Rugby Players

ObjectiveTo examine sex differences between concussion and lower-extremity musculoskeletal injury (LE-MSI) in community male and female rugby players.BackgroundThere is an ∼2x elevated risk of post-concussion subsequent MSI in high school through professional athletes. However, the effect of sex on risk is inconsistent and sparse, and rugby provides an ideal population as it’s the only collision sport with the same rules for both sexes.Design/Methods1,037 rugby players (31.6 + 11.3 years, 59.1% male), with at least one year of rugby playing experience, participated in this study, completing an online injury history questionnaire to ascertain concussion (yes/no) and LE-MSI (yes/no) history. A chi-squared test was performed to determine the association between concussion and any LE-MSI; significant findings were followed up with a post hoc odds ratio test. A binary logistic regression with any LE-MSI (yes/no) as the outcome and concussion (yes/no) and sex (male/female) as predictors was performed to determine if there was a sex by concussion interaction.ResultsThere was a significant association between concussion and any LE-MSI for all groups (Overall: ?(1) =13.06, p < 0.001, OR = 2.30 [95% CI: 1.45–3.65]; Males: ?(1) =7.43 p = 0.006, OR = 2.21 [95% CI: 1.24–3.96]; and Females: ?(1) = 5.78, p = 0.016, OR = 2.48 [95% CI: 1.16–5.31]). However, there were no differences for risk of LE-MSI between males and females (p = 0.99, R2 = 0.024).ConclusionsBoth male and female community rugby players had a 2x greater risk of LE-MSI, given a history of concussion compared to those without a history of concussion, which aligns with previous studies focused on collegiate athletes. However, there was no difference in risk of LE-MSI between sexes, contrary to smaller, but more controlled studies. Future research should investigate the potential physiological mechanisms for increased risk of LE-MSI.

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Failure in the application of fragility fracture prevention guidelines

Annals of The Royal College of Surgeons of England ◽

10.1308/003588414x13946184901164 ◽

2014 ◽

Vol 96 (5) ◽

pp. 381-385 ◽

Cited By ~ 10

Author(s):

MH Elvey ◽

H Pugh ◽

G Schaller ◽

G Dhotar ◽

B Patel ◽

...

Keyword(s):

Hip Fracture ◽

High Risk ◽

Fragility Fracture ◽

Fragility Fractures ◽

Fracture Prevention ◽

Consecutive Series ◽

National Guidelines ◽

Fracture Population ◽

The Mean ◽

The Uk

Introduction The cost of fragility fractures to the UK economy is predicted to reach £2.2 billion by 2025. We studied our hip fracture population to establish whether national guidelines on fragility fracture prevention were being followed, and whether high risk patients were identified and treated by local care services. Methods Data on a consecutive series of trauma hip fracture admissions were collected prospectively over 14 months. National Institute for Health and Care Excellence (NICE) and National Osteoporosis Guideline Group (NOGG) recommendations and FRAX® risk calculations were applied to patients prior to their admission with a new hip fracture. Results Overall, 94 patients were assessed against national guidelines. The mean population age was 77 years. Almost a quarter (22%) of patients had suffered a previous fragility fracture. The mean FRAX® ten-year probability of hip fracture was 7%. According to guidelines, 45% of the study population required treatment, 35% fulfilled criteria for investigation and reassessment, and 20% needed no further management. In practice, 27% received treatment, 4% had undergone dual energy x-ray absorptiometry and were untreated, and 69% had not been investigated and were untreated. In patients meeting intervention thresholds, only 33% of those who required treatment were receiving treatment in practice. Conclusions In conjunction with NICE and NOGG recommendations, FRAX® was able to identify 80% of our fracture population as intermediate or high risk on the day of fracture. Correct management was evident in a third of cases with a pattern of inferior guideline compliance seen in a London population. There remains a lack of clarity over the duty of care in fragility fracture prevention.

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Cardiovascular biomarkers predict fragility fractures in older adults

Heart ◽

10.1136/heartjnl-2018-313741 ◽

2018 ◽

Vol 105 (6) ◽

pp. 449-454 ◽

Cited By ~ 3

Author(s):

Madeleine Johansson ◽

Fabrizio Ricci ◽

Giuseppe Di Martino ◽

Cecilia Rogmark ◽

Richard Sutton ◽

...

Keyword(s):

Older Adults ◽

Femoral Fractures ◽

Fragility Fractures ◽

Population Based ◽

Community Dwelling ◽

Increased Risk ◽

Longitudinal Association ◽

History Of ◽

Neuroendocrine Activation

ObjectiveTo assess the role of four biomarkers of neuroendocrine activation and endothelial dysfunction in the longitudinal prediction of fragility fractures.MethodsWe analysed a population-based prospective cohort of 5415 community-dwelling individuals (mean age, 68.9±6.2 years) enrolled in the Malmö Preventive Project followed during 8.1±2.9 years, and investigated the longitudinal association between C-terminal pro-arginine vasopressin (CT-proAVP), C-terminal endothelin-1 precursor fragment (CT-proET-1), the mid-regional fragments of pro-adrenomedullin (MR-proADM) and pro-atrial natriuretic peptide (MR-proANP), and incident vertebral, pelvic and extremity fractures.ResultsOverall, 1030 (19.0%) individuals suffered vertebral, pelvic or extremity fracture. They were older (70.7±5.8 vs 68.4±6.3 years), more likely women (46.9% vs 26.3%), had lower body mass index and diastolic blood pressure, were more often on antihypertensive treatment (44.1% vs 38.4%) and had more frequently history of fracture (16.3% vs 8.1%). Higher levels of MR-proADM (adjusted HR (aHR) per 1 SD: 1.51, 95% CI 1.01 to 2.28, p<0.001) and MR-proANP (aHR: 1.23, 95% CI 1.05 to 1.45, p<0.001) were independently associated with increased risk of any fracture. The fracture risk increased linearly across MR-proANP quartiles. Individuals who were in the top quartile of all four biomarkers had a significant higher risk of fracture at any site (aHR: 2.32, 95% CI 1.86 to 2.91), vertebral fracture (aHR: 3.16, 95% CI 1.97 to 5.07) and femoral fracture (aHR: 2.35, 95% CI 1.64 to 3.36).ConclusionsElevated levels of MR-proADM and MR-proANP independently predict fragility fractures in older adults. In subjects with top quartile levels of all four biomarkers there is a twofold to threefold increase in risk of vertebral and femoral fractures.

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Risk Factors for Permanent Visual Loss in Biopsy-proven Giant Cell Arteritis: A Study of 339 Patients

The Journal of Rheumatology ◽

10.3899/jrheum.151135 ◽

2016 ◽

Vol 43 (7) ◽

pp. 1393-1399 ◽

Cited By ~ 26

Author(s):

Eric Liozon ◽

François Dalmay ◽

Fabrice Lalloue ◽

Guillaume Gondran ◽

Holy Bezanahary ◽

...

Keyword(s):

Risk Factors ◽

Giant Cell Arteritis ◽

Giant Cell ◽

Visual Loss ◽

Clinical Findings ◽

Multivariable Logistic Regression Analysis ◽

Glucocorticoid Treatment ◽

Increased Risk ◽

History Of ◽

Laboratory Variables

Objective.To determine the risk factors for permanent visual loss (PVL) in patients with biopsy-proven giant cell arteritis (GCA) and the usefulness of the factors in clinical practice.Methods.From 1976 through 2015, the clinical charts and laboratory results of 339 patients with biopsy-proven GCA were recorded prospectively at the time of diagnosis. We used multivariable logistic regression analysis to determine which of 24 pretreatment characteristics were associated with PVL.Results.Visual ischemic manifestations occurred in 108 patients, including PVL in 53 (16%), bilaterally in 15 patients (28%). The independent predictors associated with an increased risk of PVL were age (OR 1.06, 95% CI 1.01–1.12, p = 0.01), a history of transient visual ischemic symptoms (OR 2.62, 95% CI 1.29–5.29, p < 0.01), and jaw claudication (OR 2.11, 95% CI 1.09–4.10, p = 0.03). The presence of fever (OR 0.30, 95% CI 0.14–0.64, p < 0.01) and rheumatic symptoms (OR 0.23, 95% CI 0.10–0.57, p = 0.001) were associated with a markedly reduced risk of developing visual loss (3.7% if features were both present). No laboratory variables were independently associated with PVL.Conclusion.The visual ischemic risk of untreated GCA can be readily estimated upon simple clinical findings, but not laboratory variables. However, we did not identify a subgroup of patients carrying no risk of developing visual loss. Glucocorticoid treatment remains, therefore, urgent for any patient with a high clinical suspicion index.

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Impact of Androgen Deprivation Therapy on Cardiovascular Disease and Diabetes

Journal of Clinical Oncology ◽

10.1200/jco.2008.20.0923 ◽

2009 ◽

Vol 27 (21) ◽

pp. 3452-3458 ◽

Cited By ~ 212

Author(s):

Shabbir M.H. Alibhai ◽

Minh Duong-Hua ◽

Rinku Sutradhar ◽

Neil E. Fleshner ◽

Padraig Warde ◽

...

Keyword(s):

Prostate Cancer ◽

Sudden Cardiac Death ◽

Androgen Deprivation Therapy ◽

Fragility Fracture ◽

Cardiac Death ◽

Fragility Fractures ◽

Androgen Deprivation ◽

Administrative Databases ◽

Increased Risk ◽

Bilateral Orchiectomy

Purpose Use of androgen deprivation therapy (ADT) may be associated with an increased risk of diabetes mellitus but the risk of both acute myocardial infarction (AMI) and cardiovascular mortality remain controversial because few outcomes and conflicting findings have been reported. We sought to clarify whether ADT is associated with these outcomes in a large, representative cohort. Methods Using linked administrative databases in Ontario, Canada, men age 66 years or older with prostate cancer given continuous ADT for at least 6 months or who underwent bilateral orchiectomy (n = 19,079) were matched with men with prostate cancer who had never received ADT. Treated and untreated groups were matched 1:1 (ie, hard-matched) on age, prior cancer treatment, and year of diagnosis and propensity-matched on comorbidities, medications, cardiovascular risk factors, prior fractures, and socioeconomic variables. Primary outcomes were development of AMI, sudden cardiac death, and diabetes. Fragility fracture was also examined. Results The cohort was observed for a mean of 6.47 years. In time-to-event analyses, ADT use was associated with an increased risk of diabetes (hazard ratio [HR], 1.16; 95% CI, 1.11 to 1.21) and fragility fracture (HR, 1.65; 95% CI, 1.53 to 1.77) but not with AMI (HR, 0.91; 95% CI, 0.84 to 1.00) or sudden cardiac death (HR, 0.96; 95% CI, 0.83 to 1.10). Increasing duration of ADT was associated with an excess risk of fragility fractures and diabetes but not cardiac outcomes. Conclusion Continuous ADT use for at least 6 months in older men is associated with an increased risk of diabetes and fragility fracture but not AMI or sudden cardiac death.

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Postmenopausal Fracture History and Survival After Reproductive Cancer Diagnosis

JNCI Cancer Spectrum ◽

10.1093/jncics/pky001 ◽

2018 ◽

Vol 2 (1) ◽

Author(s):

Polly A Newcomb ◽

Scott V Adams ◽

Sophie Mayer ◽

Michael N Passarelli ◽

Lesley Tinker ◽

...

Keyword(s):

Breast Cancer ◽

Cancer Survivors ◽

Cancer Diagnosis ◽

Breast Cancer Survivors ◽

Postmenopausal Breast Cancer ◽

Cancer Specific Survival ◽

Estrogen Exposure ◽

Increased Risk ◽

History Of ◽

Fracture History

Abstract Background Postmenopausal bone fracture's have been proposed as a marker of lifetime estrogen exposure and have been associated with decreased risk of breast and endometrial cancer. It is plausible that prediagnostic fractures may be related to survival of estrogen-sensitive cancers. Methods We evaluated a cohort of breast (n = 6411), endometrial (n = 1127), and ovarian (n = 658) cancer cases diagnosed between 1992 and 2010 while participating in the Women’s Health Initiative. Postmenopausal fracture history was assessed from baseline reports of fractures after age 55 years and incident fractures that occurred at least one year prior to cancer diagnosis during study follow-up. Using Cox regression, we compared women with and without a history of fractures with respect to overall and cancer-specific survival. Estimates were adjusted for participant factors, including hormone therapy use; hormone receptor status was not included in our analysis. Results Among women with breast cancer, a history of prediagnostic fractures at any site was associated with poorer overall survival (hazard ratio [HR] = 1.22, 95% confidence interval [CI] = 1.05 to 1.43). A history of hip, forearm, or spine fractures, or hip fracture alone, was associated with increased risk of mortality (HR = 1.26, 95% CI = 1.01 to 1.58, and HR = 2.05, 95% CI = 1.27 to 3.32, respectively). Fracture history was associated neither with cancer-specific survival among breast cancer survivors, nor with overall or disease-specific mortality among endometrial and ovarian cancer survivors. Conclusions Postmenopausal breast cancer patients with a history of fractures, especially of the hip, are more likely to die of any cause than breast cancer survivors without a fracture history. Identifying and intervening in fracture risk factors should be standard of care for all women diagnosed with breast cancer.

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Insights into the genetics of osteoporosis from recent genome-wide association studies

Expert Reviews in Molecular Medicine ◽

10.1017/s1462399411001980 ◽

2011 ◽

Vol 13 ◽

Cited By ~ 21

Author(s):

Hou-Feng Zheng ◽

Timothy D. Spector ◽

J. Brent Richards

Keyword(s):

Rare Variants ◽

Association Studies ◽

Fragility Fractures ◽

Fracture Prevention ◽

Genome Wide Association ◽

Genome Wide Association Studies ◽

Mineral Density ◽

Genome Wide ◽

Increased Risk ◽

Genetics Of Osteoporosis

Osteoporosis, which is characterised by reduced bone mineral density (BMD) and an increased risk of fragility fractures, is the result of a complex interaction between environmental factors and genetic variants that confer susceptibility. Heritability studies have shown that BMD and other osteoporosis-related traits such as ultrasound properties of bone, skeletal geometry and bone turnover have significant inheritable components. Although previous linkage and candidate gene studies have provided few replicated loci for osteoporosis, genome-wide association approaches have produced clear and reproducible findings. To date, 20 genome-wide association studies (GWASs) for osteoporosis and related traits have been conducted, identifying dozens of genes. Further meta-analyses of GWAS data and deep resequencing of rare variants will uncover more novel susceptibility loci and ultimately provide possible therapeutic targets for fracture prevention.

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Fragility Fractures Are Associated with an Increased Risk for Cardiovascular Events in Women and Men with Rheumatoid Arthritis: A Population-based Study

The Journal of Rheumatology ◽

10.3899/jrheum.160651 ◽

2017 ◽

Vol 44 (5) ◽

pp. 558-564 ◽

Cited By ~ 6

Author(s):

Orla Ni Mhuircheartaigh ◽

Cynthia S. Crowson ◽

Sherine E. Gabriel ◽

Veronique L. Roger ◽

L. Joseph Melton ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Risk Factors ◽

Fragility Fracture ◽

Fragility Fractures ◽

Population Based ◽

Cvd Risk ◽

Cox Models ◽

Excess Morbidity ◽

Increased Risk ◽

Time Dependent Covariates

Objective.Women and men with rheumatoid arthritis (RA) have an increased risk for fragility fractures and cardiovascular disease (CVD), each of which has been reported to contribute to excess morbidity and mortality in these patients. Fragility fractures share similar risk factors for CVD but may occur at relatively younger ages in patients with RA. We aimed to determine whether a fragility fracture predicts the development of CVD in women and men with RA.Methods.We studied a population-based cohort with incident RA from 1955 to 2007 and compared it with age- and sex-matched non-RA subjects. We identified fragility fractures and CVD events following the RA incidence/index date, along with relevant risk factors. We used Cox models to examine the association between fractures and the development of CVD, in which fractures and CVD risk factors were modeled as time-dependent covariates.Results.There were 1171 subjects (822 women; 349 men) in each of the RA and non-RA cohorts. Over followup, there were 406 and 346 fragility fractures and 286 and 225 CVD events, respectively. The overall CVD risk was increased significantly for RA subjects following a fragility fracture (HR 1.81, 95% CI 1.38–2.37) but not for non-RA subjects (HR 1.18, 95% CI 0.85–1.63). Results were similar for women and men with RA.Conclusion.Fragility fractures in both women and men with RA are associated with an increased risk for CVD events and should raise an alert to clinicians to target these individuals for further screening and preventive strategies for CVD.

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