For the first time ever, a dedicated symposium was organised as a collaboration between orthopedicians and endocrinologists of New Delhi with the objective of discussing how to streamline patient management strategies for several disorders which are commonly managed by each speciality. The goal of this initiative is better treatment outcomes and patient satisfaction. Practical and relevant topics of the day were discussed and deliberated on in detail. This included vitamin-D use and misuse, practical issues with dual energy X-ray absorptiometry (DEXA) for bone health assessment, optimal use of bisphosphonates in osteoporosis, current place of denosumab in osteoporosis care, and the fading away of calcitonin. Approach to elevated parathyroid hormone, hypophosphatemia, secondary causes of osteoporosis, overdiagnosis and incorrect treatment of hyperuricemia and the rheumatologic manifestations of diabetes were discussed.
Raman Marwaha, Lajpat Nagar, New Delhi, India, discussed the pitfalls in ordering and interpreting DEXA for the diagnosis and management of osteoporosis. Importance of correct positioning, and ruling out artefacts, were discussed. Machine quality control is critical to correct DEXA reporting. Dr Marwaha also highlighted the increased role of trabecular bone score when deciding whether bone pharmacotherapy is necessary for people with osteopenia and risk factors for fractures.1 Anirban Sinha, Calcutta Medical College, Kolkata, India summarized the evolution and fading off of calcitonin use in osteoporosis management. Calcitonin was never the most potent agent in improving bone mineral density (BMD); it had only mild effects in improving vertebral BMD in some but not all studies.2 It has inconsistent effect on improving BMD or reducing fractures at non-vertebral sites. With trends of increased risk of cancer in some studies,3 only mild improvements in vertebral BMD, easy availability as well as better efficacy of bisphosphonates and teriparatide use, lead to demise of calcitonin use in osteoporosis. Mild bone analgesic effects and chondroprotective effects are some of the unique properties of calcitonin, but not novel enough to warrant use for managing osteoporosis in the 21st century, when better, safer and more-effective treatment options are available.
Rakesh Sahay, Osmania Medical College, Hyderabad, presented the current data on use of bisphosphonates both for the prevention, as well as the treatment, of osteoporosis. Alendronate and risedronate are the most popular oral bisphosphonates used in clinical practice in India. Annual zoledronate injection is the most popular injectable bisphosphonate. Its advantage over oral bisphosphonates include lower gastrointestinal side effects, no compliance issues, increased potency, and superior outcomes over all bisphosphonates with regards to improving BMD.4 The importance of drug holiday to prevent adynamic bone disease and atypical fractures, especially atypical femoral fractures, were discussed in detail. Importance of good oral hygiene to prevent osteonecrosis jaw was also discussed. Rare side effects, such as atrial fibrillation, often seen with injectable bisphosphonates, were highlighted. The importance of maintaining vitamin-D sufficiency and adequate calcium replacement before starting bisphosphonates was emphasised, both for optimal treatment outcomes, as well as for preventing hypoglycaemia.
Soumik Goswami, NRS Medical College, Kolkata, India discussed the good clinical practices with regards to use of denosumab for managing osteoporosis. Denosumab is the post potent anti-resorptive therapy currently available for managing osteoporosis. It can be used in patients with mild-to-moderate renal impairment, a population where bisphosphonates cannot be used for managing osteoporosis. Denosumab rapidly clears away from the system once the 6 monthly therapy is stopped, often resulting in rebound bone-mineral loss, a problem not associated with bisphosphonate use, as it can stay in the bones for decades.5 Hence, other treatments for osteoporosis should be initiated once denosumab is stopped. The risk for osteonecrosis jaw remains with denosumab, as with the bisphosphonates.6 Maintaining vitamin-D sufficiency and calcium sufficiency is critical to prevent hypocalcaemia as a side effect. Patients like it as it’s a small subcutaneous injection which is administered every 6 months. Currently, denosumab remains as an alternative to bisphosphonates in high-risk to very high-risk patients who do not respond to bisphosphonates. It is also used and as a second-line therapy, after teriparatide, in very high-risk patients, in those with stage 3–4 chronic kidney disease, in non-compliant patients, and in patients with life expectancy of around 10 years.
The over-diagnosis and overtreatment of hyperuricemia was discussed by Monashish Sahu, Greater Kailash, New Delhi, India. The most common cause of hyperuricemia is insulin resistance as part of a metabolic syndrome followed by different associated comorbidities.7 Although there exists a lot of correlation between hyperuricemia and comorbidities (cardiovascular disease, renal dysfunction, metabolic syndrome) from observational studies, clinical trials with urate-lowering therapies have failed show any benefit with regards to the associated co-morbidities.8 Therefore, optimal management of all comorbidities is of the utmost importance. Therapeutic lifestyle changes, weight loss and regular physical activity are useful means of improving general health. Urate-lowering therapy is not recommended in patients with asymptomatic hyperuricemia, even those with monosodium deposits, as per different international societies, such as the European League Against Rheumatism, the British Society for Rheumatology and the American College of Rheumatology.
Sanjay Bhadada, Postgraduate Institute of Medical Education & Research, Chandigarh, India shared his original research work on impaired bone health in diabetes. Both type 1 and type 2 diabetes mellitus (T1/2DM) are associated with increased fractures. T1DM is predominantly a state of reduced bone mineral content with quality, whereas, T2DM is predominantly a state of impaired bone quality Fracture risk reduction should be considered as a treatment target for diabetes, in the saw way that we use glycated haemoglobin (Hba1c) and cholesterol. Diligent selection of antidiabetic medications is warranted in people at high risk of fractures. The use of pioglitazone and sodium–glucose cotransorter-2 inhibitors should be avoided in such patients as they have been linked with impaired bone health. Meha Sharma, CEDAR Superspeciality Clinics, New Delhi, India and Aarti Sharma, Maharaj Agrasen Hospital, New Delhi, India discussed the vast topic of rheumatologic manifestations in diabetes as a duologue. In this interactive presentation, they highlighted the challenges in diagnosing the different rheumatologic manifestations of diabetes (frozen shoulder, carpel tunnel syndrome, Charcot foot, crystal induced arthritis, septic arthritis among others), variable response of improving glycaemic control on their manifestation and progression, and the need for teamwork between rheumatologists and endocrinologists in ensuring good patient outcomes.8
- Krohn K, Schwartz EN, Chung YS, Lewiecki EM. Dual-energy x-ray absorptiometry monitoring with trabecular bone score: 2019 ISCD official position. J Clin Densitom. 2019;22:501–5.
- Sun LM, Lin MC, Muo CH, Liang JA, Kao CH. Calcitonin nasal spray and increased cancer risk: a population-based nested case-control study. J Clin Endocrinol Metab. 2014;99:4259–64.
- Hsiao FY, Hsu WW. Comparative risks for cancer associated with use of calcitonin, bisphosphonates or selective estrogen receptor modulators among osteoporosis patients: a population-based cohort study. Jpn J Clin Oncol. 2017;47:935–41.
- Fardellone P, Lello S, Cano A, de Sá Moreira E, Watanabe de Oliveira R, Julian GS, Tang B. Real-world adherence and persistence with bisphosphonate therapy in postmenopausal women: a systematic review. Clin Ther. 2019;41:1576–88.
- Niimi R, Kono T, Nishihara A, Hasegawa M, Kono T, Sudo A. Second rebound-associated vertebral fractures after denosumab discontinuation. Arch Osteoporos. 2020;15:7.
- Chehal H, Nikitakis NG, Islam MN, Goodchild JH, Mordini L, Bhattacharyya I. Denosumab-related osteonecrosis of the jaw: a report of 2 cases and review of the literature. Gen Dent. 2019;67:42–6.
- Lee JH. Prevalence of hyperuricemia and its association with metabolic syndrome and cardiometabolic risk factors in Korean children and adolescents: analysis based on the 2016-2017 Korea National Health and Nutrition Examination Survey. Korean J Pediatr. 2019;62:317–23.
- Sözen T, Başaran NÇ, Tınazlı M, Özışık L. Musculoskeletal problems in diabetes mellitus. Eur J Rheumatol. 2018;5:258–65.
Support: No funding was received in the publication of this insight article.
Published: 12 March 2020
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