Doença óssea induzida pelos glicocorticoides: mecanismos e importância na prática pediátrica / Glucocorticoid-induced bone disease: mechanisms and importance in pediatric practice

RESUMO Objetivo: Descrever os mecanismos pelos quais os glicocorticoides provocam osteoporose, com risco consequente de fraturas, integrando esse conhecimento a uma possível mudança de conduta dos profissionais de saúde. Fontes de dados: Foi realizada pesquisa aprofundada nas bases de dados (SciELO, PubMed, Medline e Scopus), buscando consensos, artigos de revisão, incluindo revisões sistemáticas e meta-análises, publicados em inglês, entre 2000 e 2016. As palavras-chaves utilizadas na busca foram glicocorticoides, esteroides, fraturas, osteoporose, saúde óssea, crianças e adolescentes. Síntese dos dados: A revisão foi dividida em quatro tópicos principais: 1) introdução, com breve enfoque nas fraturas em pediatria; 2) osteoporose em crianças e adolescentes, destacando-a como causa silenciosa de fraturas; 3) glicocorticoides e doença óssea secundária, com a descrição dos mecanismos deletérios desse grupo de esteroides na estrutura óssea; 4) efeitos moleculares do excesso de glicocorticoides no osso, com o detalhamento dos mecanismos nocivos a nível molecular do tecido ósseo. Conclusões: Os glicocorticoides em excesso determinam doença óssea precoce, favorecendo a ocorrência de fraturas. Dessa forma, uma criança ou adolescente que requer corticoterapia, sobretudo crônica e sistêmica, mas também em ciclos repetidos com doses cumulativas altas, necessita de cuidados e orientações relacionados à saúde óssea logo ao início do tratamento. Por outro lado, aqueles com fratura, mesmo entrelaçada a um trauma, podem sinalizar fragilidade óssea subjacente e desconhecida, incluindo a secundária ao uso de glicocorticoides e à deficiência de vitamina D.

ABSTRACT Objective: To describe mechanisms by which glucocorticoids cause osteoporosis, with fracture risk, combining this learning with a possible professional behavior change. Data sources: A systematic search on SciELO, PubMed, Scopus, and Medline databases was carried out for consensus, review articles, including systematic reviews and meta-analysis, which were published in English, between 2000 and 2016. Keywords used on the search were the following: glucocorticoids, fractures, osteoporosis, bone health, vitamin D, children, and adolescents. Data synthesis: The review was divided into four topics: 1) introduction, with a brief focus on pediatric fractures; 2) osteoporosis in children and adolescents, highlighting it as a silent cause of fractures; 3) glucocorticoids and secondary bone disease, describing deleterious mechanisms of this steroids group on bone structure; 4) molecular effects of glucocorticoids excess on bone, with details about the harmful mechanisms on bone molecular level. Conclusions: Glucocorticoids excess determines early bone disease, favoring the occurrence of fractures. Thus, a child or an adolescent who uses glucocorticoids, especially systemically and chronically, but also repeats cycles at high cumulative doses of the medication, needs care and guidance related to bone health at the onset of treatment. On the other hand, the presence of fractures, even if related to trauma, can be a sign of underlying and unknown bone fragility, which may be secondary to the use of glucocorticoids and/or vitamin D deficiency.

Corticoides sistémicos: uso racional en dermatología / Systemic glucocorticoids: rational use in dermatology

Los glucocorticoides (GC) son potentes agentes inmunosupresores y antiinflamatorios ampliamente utilizados en el tratamiento de enfermedades dermatológicas. Las complicaciones asociadas a la terapia esteroidal sistémica aumentan con dosis mayores, tratamientos prolongados y administración fraccionada. Para maximizar la eficacia de la terapia esteroidal minimizando el riesgo de efectos adversos, es necesario conocer su farmacocinética y función a nivel de distintos órganos blanco. En esta revisión damos una visión general del mecanismo de acción de los GC y sus efectos adversos, junto con algunas recomendaciones prácticas para su uso clínico efectivo y seguro, disminuyendo el riesgo de desarrollar complicaciones.

(GC) are potent immunosuppressive and anti-inflammatory agents widely used in the treatment of many dermatologic diseases. Complications associated with systemic GC increase with higher doses, prolonged therapies, and divided administration. In order to maximize the effectiveness of steroidal therapy, minimizing the risk of adverse effects, it is necessary to know their pharmacokinetics and function on different target organs. In this review, we take general look at the mechanism of action and side effects of GC, along with some practical recommendations for their safe and effective use in order to decrease the risk of complications.

Osteoarticular complications related to HIV infection and highly active antiretroviral therapy

With the significant increase in life expectancy for HIV-infected patients in the era of high potency antiretroviral therapy, major metabolic changes have been observed due to the prolonged period of the viral infection and the treatment itself. Osteoarticular changes resulting from these processes are mainly reported in long term HIV-infected patients receiving high potency antiretroviral therapy and include osteopenia/osteoporosis, osteonecrosis, carpal tunnel syndrome and adhesive capsulitis of the shoulder.

Secondary hyperparathyroidism and calcium phosphate control in a hemodialysis population.

AIM: To evaluate the prevalence of secondary hyperparathyroidism and calcium phosphate control in the hemodialysis Asian population. METHODS: We evaluated 36 patients at Tan Tock Seng Hospital in Singapore, who were receiving thrice weekly maintenance hemodialysis for at least 6 months. Patients with history of previous parathyroidectomy were excluded from the study. Patient's weight, length of dialysis per week, duration of dialysis, serum calcium, phosphate, albumin, bicarbonate, intact parathyroid hormone (iPTH), and single pool Kt/V were retrieved from patient's medical records. RESULTS: The mean length of weekly dialysis session and single pool Kt/V was 13.5 hours and 1.73 respectively. The majority of patients achieved the target range of serum phosphorus (67%), corrected calcium (58%) and calcium times phosphate (Ca ' P) product (81%). Only 25% of patients had levels of iPTH within the target range (150-300 pg/mL). Ninety four percent of the patients were on calcium-based phosphate binder and 42% on vitamin D therapy. A significant number of patients still fell out of the recommended guideline range for serum concentrations of phosphorus (11% of patients below lower target range, 22% of patients above upper target range), corrected calcium (3% below, 39% above), calcium-phosphorus product (19% above), and iPTH (58% below, 17% above). Thirty percent of the patients had levels of iPTH < 100 pg/mL. CONCLUSION: Compared to data reported from the USA, Europe and Japan, mean levels of phosphate, corrected calcium and Ca ' P product seem better controlled in this hemodialysis Asian population. However, more than half of the patients may have oversuppression of iPTH levels and a third of patients are at increased risk of developing a dynamic bone disease.

Chemical analysis of ground water of Sanganer area, Jaipur in Rajasthan.

The chemical analysis of ground water quality of Sanganer area, Jaipur in Rajasthan is presented in this paper. It is important from this point of view to observe the suitability of water for safe drinking and irrigation. The different parameters measured are pH, conductivity, TDS, calcium, magnesium, total hardness, COD, alkalinity, Cl-, F-, PO4(3-), Na+, K+, SO4(2-), NO3-, Cd2+, Pb2+ and Fe2+. From the observed data it is found that parameters like conductivity, TDS, alkalinity, F- have high values in this area whereas other parameters are approximately with in the limits or below limit.

Correlation between osteochondral changes depicted by magnetic resonance imaging and disease progression

PURPOSE: To determine the consequences of the chronic use of systemic corticosteroids in children with juvenile rheumatoid arthritis by means of evaluating osteochondral effects depicted by magnetic resonance imaging. PATIENTS AND METHODS: We reviewed clinical and magnetic resonance imaging findings in 69 children (72 knees) with juvenile rheumatoid arthritis. Two groups were studied. Group I: 34 (49.3 percent) children had previous or current use of systemic corticotherapy (22 girls; 12 boys; mean age: 11.3 years; mean disease duration: 5.9 years; mean corticotherapy duration: 2.9 years; mean cumulative dose of previous corticosteroids: 5000 mg); Group II: 35 (50.7 percent) children had no previous use of corticosteroids (27 girls; 8 boys; mean age: 11.7 years; mean disease duration: 5.3 years). The groups were compared statistically. RESULTS: In the group that had received corticotherapy (Group I), osteochondral abnormalities were significantly correlated to long-standing disease (>3.5 years; p<0.001). This correlation was not found in the group that had no previous history of corticotherapy (Group II). No correlations were established between median dose of corticosteroids and magnetic resonance imaging findings. CONCLUSION: It is important to further investigate the long-term intra-articular effects of systemic corticotherapy to ensure that the side effects of the aggressive therapy will not be more harmful for the joints than the symptoms suffered over the natural course of the disease

Studies on skeletal muscle biopsies in endemic skeletal fluorosis.

Neurological manifestations of skeletal fluorosis have been attributed to compressive radiculomyelopathy. Experimental fluorosis has shown evidence of myopathic changes. Data on human muscle pathology is very scanty. This study included 22 patients with established osteofluorosis. 16 of them showed only EMG changes of neurogenic muscle disease. Histochemistry and histopathology of muscle biopsies showed features of muscle atrophy, evidenced by 'type I' atrophy and 'type I' grouping. No myopathic changes were observed. It may be concluded that the primary changes are related to the nerve, with muscle being affected secondarily. There was no evidence of any primary muscle pathology due to fluorosis.

Skeletal fluorosis with neurological complications.

A case of skeletal fluorosis with spinal cord compression from Kekirawa following consumption of water with high fluoride content for about 20 years is described. The observations of other workers (4,5) and the present case report show that more extensive field studies among vulnerable populations is indicated in this region. The need to search for a cost effective method of defluoridation of water is stressed.