Clinical aspects and management of osteoporosis and fragility fractures in patients with diabetes

Manju Chandran 대한골다공증학회 2017 Osteoporosis and Sarcopenia Vol.3 No.3

Both diabetes and osteoporosis are assuming epidemic proportions throughout the world. Accumulating data suggest that both types 1 and 2 diabetes are associated with an increased risk of fragility fractures. This increased risk appears to be largely independent of bone mineral density (BMD) which is most often noted to be low in type 1 diabetes and normal or increased in type 2 diabetes. This review explores the clinical characteristics of bone fragility in patients with diabetes and highlights studies that have evaluated BMD and fracture prediction tools in these patients. It also briefly reviews the current management principles of osteoporosis in diabetes, with special emphasis on the impact of diabetes medications on bone health as well as explores the efficacy of currently available antiosteoporosis pharmacotherapy in the diabetic population.

Vitamin D in COVID - 19: Dousing the fire or averting the storm? e A perspective from the Asia-Pacific

Manju Chandran,Aye Chan Maung,Ambrish Mithal,Rajeev Parameswaran 대한골다공증학회 2020 Osteoporosis and Sarcopenia Vol.6 No.3

COVID-19, the acute respiratory tract infection (RTI) caused by the Coronavirus, Sars-CoV-2, has swept around the world. No country has been spared from its onslaught. Treatments that can reduce the risk of infection and mortality from the disease are desperately needed. Though high quality randomized controlled trials are lacking, some observational and interventional studies that explore the link between vitamin D and RTIs exist. Vitamin D modulates both innate as well as adaptive immunity and may potentially prevent or mitigate the complications associated with RTIs. Evidence linking vitamin D to COVID-19 include that the outbreak occurred in winter in the northern hemisphere at a time when vitamin D levels are lowest in resident populations, that blacks and minority ethnic individuals who are known to have lower levels of vitamin D appear to be disproportionately affected and have more severe complications from the disease, that vitamin D deficiency has been shown to contribute to acute respiratory distress syndrome and that case fatality rates increase with age and in populations with comorbid conditions such as diabetes, hypertension, and cardiovascular disease, all of which are associated with lower vitamin D levels. This narrative review summarizes the current knowledge about the epidemiology and pathophysiology of COVID-19, the evidence linking vitamin D and RTIs, especially COVID-19, the mechanistic reasons behind the possible protective effect of vitamin D in COVID-19, and the evidence with regard to vitamin D supplementation in RTIs. It concludes with some recommendations regarding supplementation of vitamin D in patients with COVID-19.

Hungry bone syndrome following parathyroidectomy for primary hyperparathyroidism in a developed country in the Asia Pacific. A cohort study

Manju Chandran,John P.Bilezikian,Nurshazwani Mat Salleh,Hao Ying,Joel Lau,James Lee,Mechteld C. deJong,Aye Chan Maung,Rajeev Parameswaran 대한골다공증학회 2022 Osteoporosis and Sarcopenia Vol.8 No.1

Objectives: We sought to assess the incidence of hungry bone syndrome (HBS) following parathyroidectomy (PTX) for primary hyperparathyroidism (PHPT) in a cohort of multi-ethnic patients from a developed country in the Asia Pacific. Methods: One hundred and sixty-four patients who underwent PTX for PHPT between 2012 and 2019 at the 2 largest public hospitals in Singapore were identified. HBS was defined as serum albumin-adjusted calcium ≤ 2.1 mmol/L with normal or raised serum intact parathyroid hormone (iPTH) levels, manifesting on or after the 3rd day, or persisting for more than 3 days post-operatively. Results: Chinese constituted 73.8%, Malays 12.2%, Indians 9.8%, and other races 4.3%. HBS developed in 4 patients (2.4%) (95% CI, 0.8%-6.5%). HBS patients had significantly longer in-hospital stays; 20 days [IQR:15-22] vs 2 days [IQR:1-3]; P < 0.001in those who did not develop HBS. There was no difference in the incidence of HBS stratifying for age, sex, vitamin D status, or use of preoperative anti-resorptive medication use. For every 10 unit increase in iPTH and alkaline phosphatase (ALP) levels, the risk of HBS increased by 14% and 11%; RR (95% CI), 1.14 (1.05-1.21) and 1.11 (1.03-1.18), respectively. Conclusions: The low incidence of HBS in multi-ethnic patients undergoing PTX by multiple surgeons for PHPT at the 2 largest public hospitals that see the most such patients in Singapore, a developed country, is consistent with the asymptomatic/milder form of presentation of PHPT in the developed world.

Comparison of the Osteoporosis Self-Assessment Tool for Asians and the fracture risk assessment tool - FRAX to identify densitometric defined osteoporosis: A discriminatory value analysis in a multi-ethnic female population in Southeast Asia

Manju Chandran,Yun Ann Chin,Kuan Swen Choo,Wan Chen Ang,Xiao Feng Huang,Xiao Ming Liu,Donovan Tay,Tin Kyaw Kyaw Aung,Amin Ali,Win Pa Pa Thu,Susan Logan,Sean Xuexian Yan,Sarath Lekamwasam,Ying Hao 대한골다공증학회 2020 Osteoporosis and Sarcopenia Vol.6 No.2

Objectives: The accuracy of FRAX® as a screening tool to identify osteoporosis and how it compares with tools such as Osteoporosis Self-Assessment Tool for Asians (OSTA), in Southeast Asian women has so far been unexplored. We aimed to determine the FRAX® thresholds that accurately identify densitometric osteoporosis and to compare its performance with that of OSTA for this purpose. Methods: Singaporean postmenopausal women (n ¼ 1056) were evaluated. FRAX® Major Osteoporotic Fracture Probability (MOFP), Hip Fracture Probability (HFP) scores, and OSTA indices were calculated. Receiver operating characteristic (ROC) curves were constructed and via the Youden index, the optimal cut-off points of balanced sensitivity and specificity for dual energy X-ray absorptiometry (DXA)-defined osteoporosis were identified and the performance characteristics were compared. Results: A FRAX® MOFP threshold of ≥3.7% had sensitivity, specificity, positive predictive value and negative predictive value of 0.78 (0.73-0.83), 0.63 (0.59-0.66), 0.4 (0.36-0.44), and 0.9 (0.87-0.92), respectively in identifying osteoporosis. The corresponding values for a HFP threshold of 0.6% were 0.85 (0.80-0.89), 0.58 (0.55-0.62), 0.39 (0.35-0.43), and 0.92 (0.9-0.94) and that for an OSTA index cut-off of ≥ -1.2 were 0.76 (0.70-0.81), 0.74 (0.71-0.77), 0.48 (0.43-0.54), and 0.91 (0.88-0.93). The area under the ROC curves were 82.8% (79.9%-85.6%), 77.6% (74.2%-81%), and 79.6% (76.5%-82.8%) for OSTA, MOFP, and HFP thresholds respectively. Conclusions: FRAX® and OSTA perform comparably in identifying osteoporosis in our population. OSTA has only 2 parameters and may be simpler to use. However, FRAX® may also have a role in primary screening to identify the postmenopausal woman to be referred for DXA scanning and may help facilitate fracture risk reduction discussions with the patient.

Ability of FRAX Sri Lanka adjusted for trabecular bone score to discriminate between postmenopausal women with a recent fracture and without a fracture

Sarath Lekamwasam,Madushani Karunanayaka,Vidumini Kaluarachchi,Manju Chandran,Hasanga Rathnayake,Sewwandi Subasinghe 대한골다공증학회 2020 Osteoporosis and Sarcopenia Vol.6 No.3

Objectives: We evaluated the ability of fracture risk assessment tool (FRAX) Sri Lanka to discriminate between women with a recent fracture and without a fracture, when trabecular bone score (TBS) is added to the calculation. Methods: We studied 394 women without previous fractures and 87 women who underwent dual energy X-ray absorptiometry within 3 months after the first fragility fracture. Fracture probabilities (FP) were estimated with and without TBS using Sri Lankan FRAX model and their ability to discriminate those with and without fracture was tested. Results: Women without fractures had higher bone mineral densities (BMDs) and lower FPs, compared to those with a recent fracture. Area under curves of receiver operating characteristic for FPs unadjusted were not different from those adjusted for TBS. The odd ratios of FPs unadjusted were not different from those of adjusted. The FPs estimated with TBS were higher, hence the intervention thresholds (ITs) were higher compared to FPs estimated without TBS. Thirty-two percent of women without previous fracture were above the ITs and the inclusion of TBS increased this to 36%. The integrated discriminatory index analysis showed a 8% increase in the discriminatory slope. Conclusions: The inclusion of TBS to Sri Lankan FRAX did not show an added advantage in discriminating between postmenopausal women with a recent fracture and without a fracture. TBS inclusion in fracture risk calculation among those without previous fractures, however, showed a marginal increase in the number of women above ITs.