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1.  Patient preference in the management of postmenopausal osteoporosis with bisphosphonates 
Clinical Interventions in Aging  2006;1(4):415-423.
The leading treatments for postmenopausal osteoporosis are the nitrogen-containing bisphosphonates, which are required long term for optimal benefit. Oral bisphosphonates have proven efficacy in postmenopausal osteoporosis in clinical trials, but in practice the therapeutic benefits are often compromised by patients’ low adherence. Nonadherence to bisphosphonate therapy negatively impacts outcomes such as fracture rate; fractures are in turn associated with decreased quality of life. The most common reason cited by patients for their nonadherence is that the strict dosing instructions for bisphosphonates are difficult to follow. One aspect of bisphosphonate administration that can be changed is dosing frequency and several studies have evaluated patient preferences for different dosing schedules. Studies have shown a preference for a weekly bisphosphonate regimen versus daily dosing and it has been demonstrated that this preference for reduced dosing frequency impacts on adherence. Ibandronate is the first nitrogen-containing oral bisphosphonate for osteoporosis that can be administered in a monthly regimen and two robust clinical studies demonstrated a strong patient preference for this monthly regimen versus a weekly regimen. It is important that physicians consider patient preference when prescribing treatment for osteoporosis to ensure that the disease is effectively managed for the long-term benefit of the patient.
PMCID: PMC2699650  PMID: 18046918
postmenopausal osteoporosis; bisphosphonates; preference; adherence; ibandronate
2.  Preference for and acceptability of twoformulations of a dietary supplement containing calcium plus vitamin D3: A randomized, open-label, crossover trial in adult patients with calcium and vitamin D deficiencies* 
Background:
Preference for and acceptability of a drug are crucial for complianceand hence optimal treatment of diseases that require long-term management (eg, osteoporosis). The preference for and acceptability of a chewable tablet containing calcium and vitamin D3 and a dose-comparable effervescent powder were assessed in a Phase 4, randomized, open-label, crossover trial in 5 European countries (Sweden, Finland, Belgium, the Netherlands, and Greece).
Objective:
The aim of the present analysis was to compare the preference for and acceptability, including tolerability, of these 2 formulations based on the Belgian results of the previously mentioned study.
Methods:
Patients were recruited from 3 osteoporosis units and universityhospitals in Brussels, Liege, and Ghent, Belgium. Adult patients at risk for calcium and vitamin D deficiencies were enrolled. The study drugs included 2 formulations of a dietary supplement containing a combination of calcium plus vitamin D3: chewable tablets (calcium carbonate, 1250 mg; vitamin D3, 400 IU) (A) and effervescent powder (calcium carbonate, 1250 mg; vitamin D3, 440 IU) (B). Patients were randomly assigned to receive 1 of 2 treatment sequences: AB or BA. Both formulations were given PO BID for 14 days, with a switch to the alternate formulation occurring on day 15 of the study. Preference and acceptability were assessed using 2 questionnaires: one assessed 5 variables of acceptability using 11-point scales, and the other assessed preference using yes/no questions. Compliance and tolerability were recorded throughout the study, with unused dose counts and recording of adverse events (AEs), respectively.
Results:
The study comprised 200 patients, 199 of whom received at least 1 dose of study medication and were included in the intent-to-treat analysis (174 women, 25 men; mean age, 66 years [range, 30–87 years]). Preference data were available in 178 patients, 129 of whom (72.5%) preferred the chewable tablet compared with 34 (19.1%) who preferred the effervescent powder and 15 (8.4%) who had no preference (both, P < 0.001 vs tablet). The preference for the tablet was based on consistently and significantly higher mean scores on all 5 variables of acceptability (all, P < 0.001). The most common AEs were gastrointestinal (tablet, 27/192 patients [14.1%]; powder, 31/190 patients [16.3%]). Eighteen patients (9.0%) discontinued the trial due to ≥1 AE (12 receiving the tablet and 6 receiving the powder).
Conclusions:
In this study of preference for and acceptability of 2 formulations (chewable tablet and effervescent powder) of a dietary supplement containing a combination of calcium plus vitamin D3 in Belgian adults at risk for calcium and vitamin D deficiencies, the chewable tablet was preferred by a significant majority. Based on 5 variables, the tablet was found to be significantly more acceptable than the powder. Tolerability was similar between the 2 formulations.
doi:10.1016/j.curtheres.2005.03.003
PMCID: PMC3964541  PMID: 24672109
acceptance; calcium; elderly; formulation; osteoporosis; preference; vitamin D3
3.  Quality of Life in Sarcopenia and Frailty 
Calcified tissue international  2013;93(2):101-120.
The reduced muscle mass and impaired muscle performance that defines sarcopenia in older individuals is associated with increased risk of physical limitation and a variety of chronic diseases. It may also contribute to clinical frailty.
A gradual erosion of quality of life (QoL) has been evidenced in these individuals, although much of this research has been done using generic QoL instruments, particularly the SF-36, which may not be ideal in older populations with significant comorbidities.
This review and report of an expert meeting, presents the current definitions of these geriatric syndromes (sarcopenia and frailty). It then briefly summarises QoL concepts and specificities in older populations, examines the relevant domains of QoL and what is known concerning QoL decline with these conditions. It calls for a clearer definition of the construct of disability and argues that a disease-specific QoL instrument for sarcopenia/frailty would be an asset for future research and discusses whether there are available and validated components that could be used to this end and whether the psychometric properties of these instruments are sufficiently tested. It calls also for an approach using utility weighting to provide some cost estimates and suggests that a time trade off study could be appropriate.
doi:10.1007/s00223-013-9758-y
PMCID: PMC3747610  PMID: 23828275
Age; aging; muscle weakness; quality of life; malnutrition
4.  Patients’ preferences for osteoporosis drug treatment: a discrete-choice experiment 
Introduction
The patient’s perspective is becoming increasingly important in clinical and policy decisions. In this study, we aimed to evaluate the preferences of patients with, or at risk of, osteoporosis for medication attributes, and to establish how patients trade between these attributes.
Methods
A discrete choice experiment survey was designed and patients were asked to choose between two hypothetical unlabelled drug treatments (and an opt-out option) that vary in five attributes: efficacy in reducing the risk of fracture, type of potential common side-effects, mode and frequency of administration and out-of-pocket costs. An efficient experimental design was used to construct the treatment option choice sets and a mixed logit panel data model was used to estimate patients’ preferences and trade-offs between attributes.
Results
A total of 257 patients with, or at risk of, osteoporosis completed the experiment. As expected, patients preferred treatment with higher effectiveness and lower cost. They also preferred either an oral monthly tablet or 6-month subcutaneous injection above weekly oral tablets, 3-month subcutaneous, 3-month intravenous or yearly intravenous injections. Patients disliked being at risk of gastro-intestinal disorders more than being at risk of skin reactions and flu-like symptoms. There was significant variation in preferences across the sample for all attributes except subcutaneous injection.
Conclusions
This study revealed that osteoporotic patients preferred 6-month subcutaneous injection and oral monthly tablet, and disliked gastro-intestinal disorders. Moreover, patients were willing to pay a personal contribution or to trade treatment efficacy for better levels of other attributes. Preferences for treatment attributes varied across patients and this highlights the importance of clinical decision-making taking individual preferences into account to improve osteoporosis care.
doi:10.1186/ar4465
PMCID: PMC3979104  PMID: 24479410
5.  Efficacy and safety of strontium ranelate in the treatment of knee osteoarthritis: results of a double-blind, randomised placebo-controlled trial 
Annals of the Rheumatic Diseases  2012;72(2):179-186.
Background
Strontium ranelate is currently used for osteoporosis. The international, double-blind, randomised, placebo-controlled Strontium ranelate Efficacy in Knee OsteoarthrItis triAl evaluated its effect on radiological progression of knee osteoarthritis.
Methods
Patients with knee osteoarthritis (Kellgren and Lawrence grade 2 or 3, and joint space width (JSW) 2.5–5 mm) were randomly allocated to strontium ranelate 1 g/day (n=558), 2 g/day (n=566) or placebo (n=559). The primary endpoint was radiographical change in JSW (medial tibiofemoral compartment) over 3 years versus placebo. Secondary endpoints included radiological progression, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and knee pain. The trial is registered (ISRCTN41323372).
Results
The intention-to-treat population included 1371 patients. Treatment with strontium ranelate was associated with smaller degradations in JSW than placebo (1 g/day: −0.23 (SD 0.56) mm; 2 g/day: −0.27 (SD 0.63) mm; placebo: −0.37 (SD 0.59) mm); treatment-placebo differences were 0.14 (SE 0.04), 95% CI 0.05 to 0.23, p<0.001 for 1 g/day and 0.10 (SE 0.04), 95% CI 0.02 to 0.19, p=0.018 for 2 g/day. Fewer radiological progressors were observed with strontium ranelate (p<0.001 and p=0.012 for 1 and 2 g/day). There were greater reductions in total WOMAC score (p=0.045), pain subscore (p=0.028), physical function subscore (p=0.099) and knee pain (p=0.065) with strontium ranelate 2 g/day. Strontium ranelate was well tolerated.
Conclusions
Treatment with strontium ranelate 1 and 2 g/day is associated with a significant effect on structure in patients with knee osteoarthritis, and a beneficial effect on symptoms for strontium ranelate 2 g/day.
doi:10.1136/annrheumdis-2012-202231
PMCID: PMC3599139  PMID: 23117245
Knee Osteoarthritis; Osteoarthritis; Outcomes research
6.  Health technology assessment in osteoporosis 
We review the various aspects of health technology assessment in osteoporosis, including epidemiology and burden of disease, and assessment of the cost-effectiveness of recent advances in the treatment of osteoporosis and the prevention of fracture, in the context of the allocation of healthcare resources by decision-makers in osteoporosis. This article was prepared on the basis of a symposium held by the Belgian Bone Club and the discussions surrounding that meeting, and is based on a review and critical appraisal of the literature. Epidemiological studies confirm the immense burden of osteoporotic fractures for patients and society with lifetime risks of any fracture of the hip, spine and forearm of around 40% for women and 13% for men. The economic impact is also large, for example, Europe’s six largest countries spent €31 billion on osteoporotic fractures in 2010. Moreover, the burden is expected to increase in the future with demographic changes and increasing life expectancy. Recent advances in the management of osteoporosis include novel treatments, better fracture risk assessment notably via fracture risk algorithms, and improved adherence to medication. Economic evaluation can inform decision-makers in healthcare on the cost-effectiveness of the various interventions. Cost-effectiveness analyses suggest that the recent advances in the prevention and treatment of osteoporosis may constitute an efficient basis for the allocation of scarce healthcare resources. In summary, health technology assessment is increasingly used in the field of osteoporosis and could be very useful to help decision-makers efficiently allocate healthcare resources.
doi:10.1007/s00223-013-9724-8
PMCID: PMC3696176  PMID: 23515633
Burden of disease; cost-effectiveness; economic evaluation; health technology assessment; osteoporosis
7.  How to define responders in osteoarthritis 
Background
Osteoarthritis is a clinical syndrome of failure of the joint accompanied by varying degrees of joint pain, functional limitation, and reduced quality of life due to deterioration of articular cartilage and involvement of other joint structures.
Scope
Regulatory agencies require relevant clinical benefit on symptoms and structure modification for registration of a new therapy as a disease-modifying osteoarthritis drug (DMOAD). An international Working Group of the European Society on Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and International Osteoporosis Foundation was convened to explore the current burden of osteoarthritis, review current regulatory guidelines for the conduct of clinical trials, and examine the concept of responder analyses for improving drug evaluation in osteoarthritis.
Findings
The ESCEO considers that the major challenges in DMOAD development are the absence of a precise definition of the disease, particularly in the early stages, and the lack of consensus on how to detect structural changes and link them to clinically meaningful endpoints. Responder criteria should help identify progression of disease and be clinically meaningful. The ideal criterion should be sensitive to change over time and should predict disease progression and outcomes such as joint replacement.
Conclusion
The ESCEO considers that, for knee osteoarthritis, clinical trial data indicate that radiographic joint space narrowing >0.5 mm over 2 or 3 years might be a reliable surrogate measure for total joint replacement. On-going research using techniques such as magnetic resonance imaging and biochemical markers may allow the identification of these patients earlier in the disease process.
doi:10.1185/03007995.2013.792793
PMCID: PMC3690437  PMID: 23557069
magnetic resonance imaging; osteoarthritis; X-ray; responder; structure-modifying drug; pain
8.  Strontium ranelate in the treatment of knee osteoarthritis: new insights and emerging clinical evidence 
Osteoarthritis is a primary cause of disability and functional incapacity. Pharmacological treatment is currently limited to symptomatic management, and in advanced stages, surgery remains the only solution. The therapeutic armamentarium for osteoarthritis remains poor in treatments with an effect on joint structure, that is, disease-modifying osteoarthritis drugs (DMOADs). Glucosamine sulfate and chondroitin sulfate are the only medications for which some conclusive evidence for a disease-modifying effect is available. Strontium ranelate is currently indicated for the prevention of fracture in severe osteoporosis. Its efficacy and safety as a DMOAD in knee osteoarthritis has recently been explored in the SEKOIA trial, a 3-year randomized, double-blind, placebo-controlled trial. Outpatients with knee osteoarthritis, Kellgren and Lawrence grade 2 or 3, and joint space width (JSW) of 2.5–5 mm received strontium ranelate 1 g/day (n = 558) or 2 g/day (n = 566), or placebo (n = 559). This sizable population was aged 62.9 years and had a JSW of 3.50 ± 0.84 mm. Treatment with strontium ranelate led to significantly less progression of knee osteoarthritis: estimates for annual difference in joint space narrowing versus placebo were 0.14 mm [95% confidence interval (CI) 0.05–0.23 mm; p < 0.001] for 1 g/day and 0.10 mm (95% CI 0.02–0.19 mm; p = 0.018) for 2 g/day, with no difference between strontium ranelate groups. Radiological progression was less frequent with strontium ranelate (22% with 1 g/day and 26% with 2 g/day versus 33% with placebo, both p < 0.05), as was radioclinical progression (8% and 7% versus 12%, both p < 0.05). Symptoms also improved with strontium ranelate 2 g/day only in terms of total WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score (p = 0.045), and its components for pain (p = 0.028) and physical function (p = 0.099). Responder analyses using a range of criteria for symptoms indicated that the effect of strontium ranelate 2 g/day on pain and physical function was clinically meaningful. Strontium ranelate was well tolerated. The observation of both structure and symptom modification with strontium ranelate 2 g/day makes SEKOIA a milestone in osteoarthritis research and treatment.
doi:10.1177/1759720X13500862
PMCID: PMC3791090  PMID: 24101948
joint space narrowing; osteoarthritis; strontium ranelate; symptoms; treatment
9.  Effects of 3 months of short sessions of controlled whole body vibrations on the risk of falls among nursing home residents 
BMC Geriatrics  2013;13:42.
Background
Fatigue, lack of motivation and low compliance can be observed in nursing home residents during the practice of physical activity. Because exercises should not be too vigorous, whole body vibration could potentially be an effective alternative. The objective of this randomized controlled trial was to assess the impact of 3-month training by whole body vibration on the risk of falls among nursing home residents.
Methods
Patients were randomized into two groups: the whole body vibration group which received 3 training sessions every week composed of 5 series of only 15 seconds of vibrations at 30 Hz frequency and a control group with normal daily life for the whole study period. The impact of this training on the risk of falls was assessed blindly by three tests: the Tinetti Test, the Timed Up and Go test and a quantitative evaluation of a 10-second walk performed with a tri-axial accelerometer.
Results
62 subjects (47 women and 15 men; mean age 83.2 ± 7.99 years) were recruited for the study. No significant change in the studied parameters was observed between the treated (n=31) and the control group (n=31) after 3 months of training by controlled whole-body-vibrations. Actually, the Tinetti test increased of + 0.93 ± 3.14 points in the treated group against + 0.88 ± 2.33 points in the control group (p = 0.89 when adjusted). The Timed Up and Go test showed a median evolution of - 1.14 (− 4.75-3.73) seconds in the treated group against + 0.41 (− 3.57- 2.41) seconds in the control group (p = 0.06). For the quantitative evaluation of the walk, no significant change was observed between the treated and the control group in single task as well as in dual task conditions.
Conclusions
The whole body vibration training performed with the exposition settings such as those used in this research was feasible but seems to have no impact on the risk of falls among nursing home residents. Further investigations, in which, for example, the exposure parameters would be changed, seem necessary.
Trial registration
Trial registration number: NCT01759680
doi:10.1186/1471-2318-13-42
PMCID: PMC3649886  PMID: 23647914
Whole-body-vibration; Nursing home; Falls
10.  Health Technology Assessment in Osteoporosis 
We review the various aspects of health technology assessment in osteoporosis, including epidemiology and burden of disease, and assessment of the cost-effectiveness of recent advances in the treatment of osteoporosis and the prevention of fracture, in the context of the allocation of health-care resources by decision makers in osteoporosis. This article was prepared on the basis of a symposium held by the Belgian Bone Club and the discussions surrounding that meeting and is based on a review and critical appraisal of the literature. Epidemiological studies confirm the immense burden of osteoporotic fractures for patients and society, with lifetime risks of any fracture of the hip, spine, and forearm of around 40 % for women and 13 % for men. The economic impact is also large; for example, Europe’s six largest countries spent €31 billion on osteoporotic fractures in 2010. Moreover, the burden is expected to increase in the future with demographic changes and increasing life expectancy. Recent advances in the management of osteoporosis include novel treatments, better fracture-risk assessment notably via fracture risk algorithms, and improved adherence to medication. Economic evaluation can inform decision makers in health care on the cost-effectiveness of the various interventions. Cost-effectiveness analyses suggest that the recent advances in the prevention and treatment of osteoporosis may constitute an efficient basis for the allocation of scarce health-care resources. In summary, health technology assessment is increasingly used in the field of osteoporosis and could be very useful to help decision makers efficiently allocate health-care resources.
doi:10.1007/s00223-013-9724-8
PMCID: PMC3696176  PMID: 23515633
Burden of disease; Cost-effectiveness; Economic evaluation; Health technology assessment; Osteoporosis
11.  Nominal group technique to select attributes for discrete choice experiments: an example for drug treatment choice in osteoporosis 
Background:
Attribute selection represents an important step in the development of discrete-choice experiments (DCEs), but is often poorly reported. In some situations, the number of attributes identified may exceed what one may find possible to pilot in a DCE. Hence, there is a need to gain insight into methods to select attributes in order to construct the final list of attributes. This study aims to test the feasibility of using the nominal group technique (NGT) to select attributes for DCEs.
Methods:
Patient group discussions (4–8 participants) were convened to prioritize a list of 12 potentially important attributes for osteoporosis drug therapy. The NGT consisted of three steps: an individual ranking of the 12 attributes by importance from 1 to 12, a group discussion on each of the attributes, including a group review of the aggregate score of the initial rankings, and a second ranking task of the same attributes.
Results:
Twenty-six osteoporotic patients participated in five NGT sessions. Most (80%) of the patients changed their ranking after the discussion. However, the average initial and final ranking did not differ markedly. In the final ranking, the most important medication attributes were effectiveness, side effects, and frequency and mode of administration. Some (15%) of the patients did not correctly rank from 1 to 12, and the order of attributes did play a role in the ranking.
Conclusion:
The NGT is feasible for selecting attributes for DCEs. Although in the context of this study, the NGT session had little impact on prioritizing attributes, this approach is rigorous, transparent, and improves the face validity of DCEs. Additional research in other contexts (different decisional problems or different diseases) is needed to determine the added value of the NGT session, to assess the optimal ranking/rating method with control of ordering effects, and to compare the attributes selected with the different approaches.
doi:10.2147/PPA.S38408
PMCID: PMC3572758  PMID: 23412964
discrete choice experiment; nominal group technique; patient preference; medication attributes; osteoporosis
12.  Translation validation of a new back pain screening questionnaire (the STarT Back Screening Tool) in French 
Archives of Public Health  2012;70(1):12.
Background
Low back pain (LBP) is a major public health problem and the identification of individuals at risk of persistent LBP poses substantial challenges to clinical management. The STarT Back questionnaire is a validated nine-item patient self-report questionnaire that classifies patients with LBP at low, medium or high-risk of poor prognosis for persistent non-specific LBP. The objective of this study was to translate and cross-culturally adapt the English version of the STarT Back questionnaire into French.
Methods
The translation was performed using best practice translation guidelines. The following phases were performed: contact with the STarT Back questionnaire developers, initial translations (English into French), synthesis, back translations, expert committee review, test of the pre-final version on 44 individuals with LBP, final version.
Results
The linguistic translation required minor semantic alterations. The participants interviewed indicated that all items of the questionnaire were globally clear and comprehensible. However, 6 subjects (14%) wondered if two questions were related to back pain or general health. After discussion within the expert committee and with the developer of the STarT Back tool, it was decided to modify the questionnaire and to add a reference to back pain in these two questions.
Conclusions
The French version of the STarT Back questionnaire has been shown to be comprehensible and adapted to the French speaking general population. Investigations are now required to test the psychometric properties (reliability, internal and external validity, responsiveness) of this translated version of the questionnaire.
doi:10.1186/0778-7367-70-12
PMCID: PMC3436683  PMID: 22958224
Low back pain; Questionnaire; Translation
13.  Role of glucosamine in the treatment for osteoarthritis 
Rheumatology International  2012;32(10):2959-2967.
Over the last 20 years, several studies have investigated the ability of glucosamine sulfate to improve the symptoms (pain and function) and to delay the structural progression of osteoarthritis. There is now a large, convergent body of evidence that glucosamine sulfate, given at a daily oral dose of 1,500 mg, is able to significantly reduce the symptoms of osteoarthritis in the lower limbs. This dose of glucosamine sulfate has also been shown, in two independent studies, to prevent the joint space narrowing observed at the femorotibial compartment in patients with mild-to-moderate knee osteoarthritis. This effect also translated into a 50 % reduction in the incidence of osteoarthritis-related surgery of the lower limbs during a 5-year period following the withdrawal of the treatment. Some discrepancies have been described between the results of studies performed with a patent-protected formulation of glucosamine sulfate distributed as a drug and those having used glucosamine preparations purchased from global suppliers, packaged, and sold over-the-counter as nutritional supplements.
doi:10.1007/s00296-012-2416-2
PMCID: PMC3456914  PMID: 22461188
Glucosamine; Osteoarthritis; Treatment; Symptoms; Structure
14.  Adverse Reactions and Drug–Drug Interactions in the Management of Women with Postmenopausal Osteoporosis 
Calcified Tissue International  2011;89(2):91-104.
The pharmacological management of disease should involve consideration of the balance between the beneficial effects of treatment on outcome and the probability of adverse effects. The aim of this review is to explore the risk of adverse drug reactions and drug–drug interactions with treatments for postmenopausal osteoporosis. We reviewed evidence for adverse reactions from regulatory documents, randomized controlled trials, pharmacovigilance surveys, and case series. Bisphosphonates are associated with gastrointestinal effects, musculoskeletal pain, and acute-phase reactions, as well as, very rarely, atrial fibrillation, atypical fracture, delayed fracture healing, osteonecrosis of the jaw, hypersensitivity reactions, and renal impairment. Cutaneous effects and osteonecrosis of the jaw are of concern for denosumab (both very rare), though there are no pharmacovigilance data for this agent yet. The selective estrogen receptor modulators are associated with hot flushes, leg cramps, and, very rarely, venous thromboembolism and stroke. Strontium ranelate has been linked to hypersensitivity reactions and venous thromboembolism (both very rare) and teriparatide with headache, nausea, dizziness, and limb pain. The solidity of the evidence base depends on the frequency of the reaction, and causality is not always easy to establish for the very rare adverse reactions. Drug–drug interactions are rare. Osteoporosis treatments are generally safe and well tolerated, though they are associated with a few very rare serious adverse reactions. While these are a cause for concern, the risk should be weighed against the benefits of treatment itself, i.e., the prevention of osteoporotic fracture.
doi:10.1007/s00223-011-9499-8
PMCID: PMC3135835  PMID: 21637997
Osteoporosis; Adverse drug reaction; Drug–drug interaction; Bisphosphonate; Denosumab; SERM; Strontium ranelate; Teriparatide
15.  Cutaneous Side Effects of Antiosteoporosis Treatments 
Cutaneous adverse reactions are reported for many therapeutic agents and, in general, are observed in between 0% and 8% of treated patients depending on the drug. Antiosteoporotic agents are considered to be safe in terms of cutaneous effects, however there have been a number of case reports of cutaneous adverse reactions which warrant consideration. This was the subject of a working group meeting of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis in April 2009, which focused on the impact of cutaneous adverse reactions and drug-induced hypersensitivity in the management of postmenopausal osteoporosis. This position paper was drafted following these discussions and includes a flowchart for their recognition. Cutaneous adverse reactions observed with antiosteoporotic agents were reviewed and included information from case reports, regulatory documents and pharmacovigilance. These reactions ranged from benign effects including exanthematous or maculopapular eruption (drug rash), photosensitivity and urticaria, to the severe and potentially life-threatening reactions of angioedema, drug rash with eosinophilia and systemic symptoms (DRESS), Stevens Johnson syndrome and toxic epidermal necrolysis. A review of the available evidence demonstrates that cutaneous adverse reactions occur with all commonly used antiosteoporotic treatments. Notably, there are reports of Stevens Johnson syndrome and toxic epidermal necrolysis for bisphosphonates, and of DRESS and toxic epidermal necrolysis for strontium ranelate. These severe reactions remain very rare (<1 in 10,000 cases). In general, with proper management and early recognition, including immediate and permanent withdrawal of the culprit agent, accompanied by hospitalization, rehydration and systemic corticosteroids if necessary, the prognosis is positive.
doi:10.1177/1759720X10387202
PMCID: PMC3383534  PMID: 22870464
antiosteoporosis treatments; cutaneous adverse reactions; hypersensitivity reactions; osteoporosis
16.  Strontium Ranelate: Long-Term Efficacy against Vertebral, Nonvertebral and Hip Fractures in Patients with Postmenopausal Osteoporosis 
Osteoporosis treatments need to combine an unequivocally demonstrated reduction of fractures, at various skeletal sites, long-term safety, and a user-friendly profile, optimizing therapeutic adherence. Strontium ranelate is the first compound to simultaneously decrease bone resorption and stimulate bone formation. Its antifracture efficacy, at various skeletal sites, has been established up to 8 years, through studies of the highest methodological standards. Increases in bone mineral density, observed after 1 year of treatment, are predictive of the long-term fracture efficacy, hence suggesting, for the first time in osteoporosis, that bone densitometry can be used as a monitoring tool for both efficacy and compliance. Owing to a positive benefit/risk ratio, strontium ranelate may now be considered as a first-line treatment in the management of osteoporosis.
doi:10.1177/1759720X10362824
PMCID: PMC3382672  PMID: 22870443
Fractures; hip; osteoporosis; safety; spine; strontium ranelate; treatment
17.  Evaluation of symptomatic slow-acting drugs in osteoarthritis using the GRADE system 
Background
Symptomatic slow-acting drugs (SYSADOA) have been largely studied over the last decade. The objective of this study is to prepare a document providing recommendations for the use of SYSADOA in osteoarthritis (OA).
Methods
The following interventions were taken into consideration: avocado/soybean unsaponifiables, chondroitin sulfate, diacereine, glucosamine sulfate, hyaluronic acid, oral calcitonin, risedronate, strontium ranelate. Recommendations were based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The GRADE system is based on a sequential assessment of the quality of evidence, followed by assessment of the balance between benefits versus downsides and subsequent judgment about the strength of recommendations.
Results
Chondroitin sulfate, diacereine, glucosamine sulfate, avocado/soybean unsaponifiables and hyaluronic acid have demonstrated pain reduction and physical function improvement with very low toxicity, with moderate to high quality evidence. Even if pre-clinical data and some preliminary in vivo studies have suggested that oral calcitonin and strontium ranelate could be of potential interest in OA, additional well-designed studies are needed.
Conclusion
In the benefit/risk ratio, the use of chondroitin sulfate, diacereine, glucosamine sulfate, avocado/soybean unsaponifiables and hyaluronic acid could be of potential interest for the symptomatic management of OA.
doi:10.1186/1471-2474-9-165
PMCID: PMC2627841  PMID: 19087296
18.  Long-term retention on treatment with lumiracoxib 100 mg once or twice daily compared with celecoxib 200 mg once daily: A randomised controlled trial in patients with osteoarthritis 
Background
The efficacy, safety and tolerability of lumiracoxib, a novel selective cyclooxygenase-2 (COX-2) inhibitor, has been demonstrated in previous studies of patients with osteoarthritis (OA). As it is important to establish the long-term safety and efficacy of treatments for a chronic disease such as OA, the present study compared the effects of lumiracoxib at doses of 100 mg once daily (o.d.) and 100 mg twice daily (b.i.d.) with those of celecoxib 200 mg o.d. on retention on treatment over 1 year.
Methods
In this 52-week, multicentre, randomised, double-blind, parallel-group study, male and female patients (aged at least 40 years) with symptomatic primary OA of the hip, knee, hand or spine were randomised (1:2:1) to lumiracoxib 100 mg o.d. (n = 755), lumiracoxib 100 mg b.i.d. (n = 1,519) or celecoxib 200 mg o.d. (n = 758). The primary objective of the study was to demonstrate non-inferiority of lumiracoxib at either dose compared with celecoxib 200 mg o.d. with respect to the 1-year retention on treatment rate. Secondary outcome variables included OA pain in the target joint, patient's and physician's global assessments of disease activity, Short Arthritis assessment Scale (SAS) total score, rescue medication use, and safety and tolerability.
Results
Retention rates at 1 year were similar for the lumiracoxib 100 mg o.d., lumiracoxib 100 mg b.i.d. and celecoxib 200 mg o.d. groups (46.9% vs 47.5% vs 45.3%, respectively). It was demonstrated that retention on treatment with lumiracoxib at either dose was non-inferior to celecoxib 200 mg o.d. Similarly, Kaplan-Meier curves for the probability of premature discontinuation from the study for any reason were similar across the treatment groups. All three treatments generally yielded comparable results for the secondary efficacy variables and all treatments were well tolerated.
Conclusion
Long-term treatment with lumiracoxib 100 mg o.d., the recommended dose for OA, was as effective and well tolerated as celecoxib 200 mg o.d. in patients with OA.
Trial registration
clinicaltrials.gov NCT00145301
doi:10.1186/1471-2474-9-32
PMCID: PMC2322990  PMID: 18328090
19.  Vitamin D inadequacy in Belgian postmenopausal osteoporotic women 
BMC Public Health  2007;7:64.
Background
Inadequate serum vitamin D [25(OH)D] concentrations are associated with secondary hyperparathyroidism, increased bone turnover and bone loss, which increase fracture risk. The objective of this study is to assess the prevalence of inadequate serum 25(OH)D concentrations in postmenopausal Belgian women. Opinions with regard to the definition of vitamin D deficiency and adequate vitamin D status vary widely and there are no clear international agreements on what constitute adequate concentrations of vitamin D.
Methods
Assessment of 25-hydroxyvitamin D [25(OH)D] and parathyroid hormone was performed in 1195 Belgian postmenopausal women aged over 50 years. Main analysis has been performed in the whole study population and according to the previous use of vitamin D and calcium supplements. Four cut-offs of 25(OH)D inadequacy were fixed : < 80 nmol/L, <75 nmol/L, < 50 nmol/L and < 30 nmol/L.
Results
Mean (SD) age of the patients was 76.9 (7.5) years, body mass index was 25.7 (4.5) kg/m2. Concentrations of 25(OH)D were 52.5 (21.4) nmol/L. In the whole study population, the prevalence of 25(OH)D inadequacy was 91.3 %, 87.5 %, 43.1 % and 15.9% when considering cut-offs of 80, 75, 50 and 30 nmol/L, respectively. Women who used vitamin D supplements, alone or combined with calcium supplements, had higher concentrations of 25(OH)D than non-users. Significant inverse correlations were found between age/serum PTH and serum 25(OH)D (r = -0.23/r = -0.31) and also between age/serum PTH and femoral neck BMD (r = -0.29/r = -0.15). There is a significant positive relation between age and PTH (r = 0.16), serum 25(OH)D and femoral neck BMD (r = 0.07). (P < 0.05)
Vitamin D concentrations varied with the season of sampling but did not reach statistical significance (P = 0.09).
Conclusion
This study points out a high prevalence of vitamin D inadequacy in Belgian postmenopausal osteoporotic women, even among subjects receiving vitamin D supplements.
doi:10.1186/1471-2458-7-64
PMCID: PMC1866237  PMID: 17462085
21.  Treatment of postmenopausal osteoporosis 
BMJ : British Medical Journal  2005;330(7496):859-860.
PMCID: PMC556145  PMID: 15831851
22.  Genetic markers of osteoarticular disorders: facts and hopes 
Arthritis Research  2001;3(5):270-280.
Osteoarthritis and osteoporosis are the two most common age-related chronic disorders of articular joints and skeleton, representing a major public health problem in most developed countries. Apart from being influenced by environmental factors, both disorders have a strong genetic component, and there is now considerable evidence from large population studies that these two disorders are inversely related. Thus, an accurate analysis of the genetic component of one of these two multifactorial diseases may provide data of interest for the other. However, the existence of confounding factors must always be borne in mind in interpreting the genetic analysis. In addition, each patient must be given an accurate clinical evaluation, including family history, history of drug treatments, lifestyle, and environment, in order to reduce the background bias. Here, we review the impact of recent work in molecular genetics suggesting that powerful molecular biology techniques will soon make possible both a rapid accumulation of data on the genetics of both disorders and the development of novel diagnostic, prognostic, and therapeutic approaches.
doi:10.1186/ar316
PMCID: PMC128904  PMID: 11549368
candidate genes; genetics; multifactorial diseases; osteoporosis; osteoarthritis
23.  Five Years of Cenosumab Exposure in Women With Postmenopausal Osteoporosis: Results From the First Two Years of the FREEDOM Extension 
The 3-year FREEDOM trial assessed the efficacy and safety of 60 mg denosumab every 6 months for the treatment of postmenopausal women with osteoporosis. Participants who completed the FREEDOM trial were eligible to enter an extension to continue the evaluation of denosumab efficacy and safety for up to 10 years. For the extension results presented here, women from the FREEDOM denosumab group had 2 more years of denosumab treatment (long-term group) and those from the FREEDOM placebo group had 2 years of denosumab exposure (cross-over group). We report results for bone turnover markers (BTMs), bone mineral density (BMD), fracture rates, and safety. A total of 4550 women enrolled in the extension (2343 long-term; 2207 cross-over). Reductions in BTMs were maintained (long-term group) or occurred rapidly (cross-over group) following denosumab administration. In the long-term group, lumbar spine and total hip BMD increased further, resulting in 5-year gains of 13.7% and 7.0%, respectively. In the cross-over group, BMD increased at the lumbar spine (7.7%) and total hip (4.0%) during the 2-year denosumab treatment. Yearly fracture incidences for both groups were below rates observed in the FREEDOM placebo group and below rates projected for a “virtual untreated twin” cohort. Adverse events did not increase with long-term denosumab administration. Two adverse events in the cross-over group were adjudicated as consistent with osteonecrosis of the jaw. Five-year denosumab treatment of women with postmenopausal osteoporosis maintained BTM reduction and increased BMD, and was associated with low fracture rates and a favorable risk/benefit profile. © 2012 American Society for Bone and Mineral Research
doi:10.1002/jbmr.1479
PMCID: PMC3415620  PMID: 22113951
BONE MINERAL DENSITY; BONE TURNOVER MARKERS; DENOSUMAB; FRACTURE; PIVOTAL FRACTURE TRIAL EXTENSION

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