26 April 2022

NSAIDs blunt clodronate fracture benefits

Diet Drugs Exercise Osteoporosis TGA

PLUS: Bimekizumab TGA approved for psoriasis, and splint vs steroids for carpal tunnel syndrome.


Concomitant use of NSAIDs and bisphosphonates is relatively common, so research finding that NSAIDs significantly reduced the efficacy of clodronate has raised concern.

Plus:

  • Bimekizumab TGA approved for psoriasis
  • Little long-term difference between night splinting vs corticosteroid injection for carpal tunnel syndrome
  • Lifestyle behaviour recommendations for people with rheumatic and musculoskeletal diseases

Reduced ability of clodronate to prevent bone loss and fractures is “unique and of high clinical importance”

Research from Sheffield in the UK has explored the relationship between NSAID use and fracture risk in a cohort of women taking clodronate and found that NSAIDs appeared to negate the bone-protective effects of the oral bisphosphonate on preventing osteoporotic fractures.

The post hoc analysis was based on over 5000 community-dwelling women aged 75 years and older taking part in a placebo-controlled study of clodronate, of whom just over 1000 were also prescribed NSAIDs.

Among those taking clodronate, NSAID use was associated with a borderline significant 37% higher risk of osteoporotic fracture in the unadjusted model (p=0.053). However, when adjusted for age, femoral neck BMD, weight, osteoarthritis, medication use and functional tests, NSAIDs increased risk of fracture by 49% (p=0.019).

In the placebo group, there was no difference in osteoporotic fractures between those taking NSAIDs and those who were not. The fracture risk for people taking clodronate and NSAIDs was similar to that of the placebo group, implying that NSAIDs appeared to negate the bone-protective effects of clodronate on preventing osteoporotic fractures.

“Although we found little evidence for NSAID use as a risk factor for incident osteoporotic fractures among elderly community-dwelling women, the observation that NSAID use significantly reduced the ability of clodronate to prevent bone loss and fractures is unique and of high clinical importance,” the authors wrote.

“The marked reduction in efficacy does not appear to be mediated by imbalances in baseline characteristics or lower compliance,” they added.

Senior author, Professor Eugene McCloskey of the University of Sheffield, urged caution in extrapolating these data to more widely used bisphosphonates in osteoporosis. However, the adult bone disease professor added in a press release, “given that concomitant usage of NSAIDs and bisphosphonates is relatively common, this could have major clinical consequences and result in a failure to reduce fracture risk as much as we had hoped.”

Journal of Bone and Mineral Research 2022, online 20 April

Bimekizumab TGA approved for psoriasis

The TGA has approved bimekizumab (Bimselx, UCB) for moderate to severe plaque psoriasis. Approval was based on research showing skin clearance was better in adults taking the drug, compared to those taking a placebo, ustekinumab, secukinumab or adalimumab, and that the drug was well tolerated.   

Bimekizumab is a new class of therapy for the chronic inflammatory condition, and selectively inhibits interleukin 17A (IL-17A) and interleukin 17F (IL-17F), two cytokines that contribute to inflammation.

Doctors can prescribe the medication to patients who qualify for systemic therapy or phototherapy. Eligible patients are initially given a loading dose of 320mg (2 x 160 mg subcutaneous injections) in four-week intervals until month four. Following the 16th dose, patients should be given a maintenance dose of 320mg every eight weeks, according to the manufacturer. 

The medication is contraindicated in those with hypersensitivity to the active substance or excipients of the drug. Live vaccines should not be administered while patients are taking the medication.

The manufacturer has applied for a PBS listing of bimekizumab but would not provide a cost price of the injection for patients seeking it without government funding.  
– Jaina Sacranie

Little long-term difference between night splinting vs corticosteroid injection for carpal tunnel syndrome

A clinical trial comparing night splinting (NS) and corticosteroid injection (CSI) in over 200 patients with carpal tunnel syndrome has found similar long-term efficacy in the two groups. However, the estimated cost of CSI over the 24-month treatment and follow-up period was slightly more than for patients receiving NS.

The UK study set out to investigate the clinical and cost-effectiveness of a one-off corticosteroid injection vs a night splint worn for 6 weeks in this patient group, noting that other studies were only short-term.

In previously published data for the current study, patients receiving CSI had significantly greater improvements in pain and function at 6 weeks than NS. However, at 6 months there were no significant differences between groups and the newly available data showed no difference at 12 or 24 months.

Over the 24 months, 28% of the CSI group were referred for carpal tunnel surgery versus 20% of the NS patients, with 22% vs 16% undergoing surgery respectively. Further treatment was also required, with some patients in both groups receiving NS or CSI after the initial 6-week treatment period. There were more visits to health professionals in the NS group, but higher costs for other aspects of treatment in the CSI group. Quality-adjusted life-years (QALY) scores were higher in the NS than the CSI group.

“This gives patients a clear choice, CSI is the treatment of choice if short-term benefit is required, but the patient needs to be counselled that it is unlikely to alter the overall course of the condition,” wrote the authors.

Rheumatology 2022, online 8 April

EULAR lifestyle behaviour recommendations for people with rheumatic and musculoskeletal diseases

A EULAR-convened taskforce of 19 experts encompassing rheumatology, gerontology, epidemiology, public health and patient groups has developed a set of recommendations on lifestyle behaviours for patients with rheumatic and musculoskeletal diseases (RMDs).

Based on an extensive review of the literature, the resulting five overarching principles emphasised the importance and benefits of a healthy lifestyle in conjunction with medical treatment, as well as the role of the health professionals in discussing and individualising lifestyle factors.

The taskforce agreed on 18 exposure-specific recommendations that covered exercise, diet, weight, alcohol consumption, smoking and workforce participation, with the full set of recommendations published in the Annals of the Rheumatic Diseases.

The authors noted that while there were unlikely to be any surprises in the recommendations, they could “serve as a foundation for discussion and shared decision-making regarding positive modifications to the lifestyles of people with RMDs, with the ultimate goal being improvements in symptoms, quality of life and long-term outcomes.”

The next step, said the authors, was to get the recommendations out into RMD community and to encourage people with RMDs to implement them with the support of health professionals and family or friends.

Ann Rheum Dis 2022, online 8 March