Novel formulations of oral bisphosphonates in the treatment of osteoporosis.

Oral bisphosphonates are a key intervention in the treatment of osteoporosis and in reducing the risk of fragility fractures. Their use is supported by over 3 decades of evidence; however, patient adherence to oral bisphosphonates remains poor in part due to complex dosing instructions and adverse events, including upper gastrointestinal symptoms. This problem has led to the development of novel oral bisphosphonate formulations. Buffered, effervescent alendronate is dissolved in water and so seeks to reduce upper gastro-intestinal adverse events, and gastro-resistant risedronate aims to reduce the complexity of dosing procedure (e.g. fasting prior to consumption) whilst still maintaining the efficacy of fracture risk reduction. Clinical trials and real-world data have been employed to demonstrate some benefits in terms of reduced upper gastro-intestinal adverse events, adherence, persistence and health economic outcomes. This report describes the result of an ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis) expert working group, which explores where oral bisphosphonates sit in current clinical practice guidelines, review their risk-benefit profile and the consequences of poor adherence before exploring novel oral bisphosphonate formulations and their potential clinical and health economic impact. Further research is required but there are signs that these novel, oral bisphosphonate formulations may lead to improved tolerance of oral bisphosphonates and thus, improved adherence and fracture outcomes.

Multimodal Multidisciplinary Management of Patients with Moderate to Severe Pain in Knee Osteoarthritis: A Need to Meet Patient Expectations.

Knee osteoarthritis (OA) is one of the most common and disabling medical conditions. In the case of moderate to severe pain, a single intervention may not be sufficient to allay symptoms and improve quality of life. Examples include first-line, background therapy with symptomatic slow-acting drugs for OA (SYSADOAs) or non-steroidal anti-inflammatory drugs (NSAIDs). Therefore, the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) performed a review of a multimodal/multicomponent approach for knee OA therapy. This strategy is a particularly appropriate solution for the management of patients affected by knee OA, including those with pain and dysfunction reaching various thresholds at the different joints. The multimodal/multicomponent approach should be based, firstly, on different combinations of non-pharmacological and pharmacological interventions. Potential pharmacological combinations include SYSADOAs and NSAIDs, NSAIDs and weak opioids, and intra-articular treatments with SYSADOAs/NSAIDs. Based on the available evidence, most combined treatments provide benefit beyond single agents for the improvement of pain and other symptoms typical of knee OA, although further high-quality studies are required. In this work, we have therefore provided new, patient-centered perspectives for the management of knee OA, based on the concept that a multimodal, multicomponent, multidisciplinary approach, applied not only to non-pharmacological treatments but also to a combination of the currently available pharmacological options, will better meet the needs and expectations of patients with knee OA, who may present with various phenotypes and trajectories.

[Impact of COVID-19 on telemedicine in diabetes management: the Belgian experience]. / Impact du Covid-19 sur la télémédecine en diabétologie : l'expérience belge.

We will briefly review the history of telemedicine. Then we will look at its various applications, including teleconsultation, which is only one part of telemedicine. Belgium had not evolved much in the field of teleconsultation. It was only during the COVID-19 pandemic that this possibility was quickly made available to caregivers, and therefore to patients. We will discuss how the Belgian authorities were able to speed up the possibility of using this branch of telemedicine. We will focus more specifically on the care of diabetic patients, particularly in our institution, the University Hospital of Liège in Belgium. Finally, we will discuss the limits and prospects of telemedicine, particularly in the field of diabetology.

Nous allons revoir brièvement l'historique de la télémédecine. Ensuite nous aborderons ses différentes applications, dont fait partie la téléconsultation, qui est une partie de la télémédecine. La Belgique n'avait que peu évolué en matière de téléconsultation. Il a fallu que la pandémie de Covid-19 arrive pour que cette possibilité soit rapidement offerte aux soignants, et donc aux patients. Nous aborderons comment les autorités belges ont pu accélérer la possibilité d'avoir recours à cette branche de la télémédecine. Nous nous focaliserons plus spécifiquement sur la prise en charge des patients diabétiques, en particulier dans notre institution, à savoir le CHU de Liège en Belgique. Enfin, nous aborderons les limites et les perspectives de la télémédecine, en particulier dans le domaine de la diabétologie.

Management of hand osteoarthritis: from an US evidence-based medicine guideline to a European patient-centric approach.

Hand osteoarthritis is the most common joint condition and is associated with significant morbidity. It is of paramount importance that patients are thoroughly assessed and examined when complaining of hand stiffness, pain, deformity or disability and that the patient's concerns and expectations are addressed by the healthcare professional. In 2019 the American College of Rheumatology and Arthritis Foundation (ACR/AF) produced guidelines which included recommendations for the treatment of hand osteoarthritis. An ESCEO expert working group (including patients) was convened and composed this paper with the aim to assess whether these guidelines were appropriate for the treatment of hand osteoarthritis therapy in Europe and whether they met with the ESCEO patient-centered approach. Indeed, patients are the key stakeholders in healthcare and eliciting the patient's preference is vital in the context of an individual consultation but also for informing research and policy-making. The patients involved in this working group emphasised the often-neglected area of aesthetic changes in hand osteoarthritis, importance of developing pharmacological therapies which can alleviate pain and disability and the need of the freedom to choose which approach (out of pharmacological, surgical or non-pharmacological) they wished to pursue. Following robust appraisal, it was recommended that the ACR/AF guidelines were suitable for a European context (as described within the body of the manuscript) and it was emphasised that patient preferences are key to the success of individual consultations, future research and future policy-making.

Management of patients at very high risk of osteoporotic fractures through sequential treatments.

Osteoporosis care has evolved markedly over the last 50 years, such that there are now an established clinical definition, validated methods of fracture risk assessment and a range of effective pharmacological agents. Currently, bone-forming (anabolic) agents, in many countries, are used in those patients who have continued to lose bone mineral density (BMD), patients with multiple subsequent fractures or those who have fractured despite treatment with antiresorptive agents. However, head-to-head data suggest that anabolic agents have greater rapidity and efficacy for fracture risk reduction than do antiresorptive therapies. The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) convened an expert working group to discuss the tools available to identify patients at high risk of fracture, review the evidence for the use of anabolic agents as the initial intervention in patients at highest risk of fracture and consider the sequence of therapy following their use. This position paper sets out the findings of the group and the consequent recommendations. The key conclusion is that the current evidence base supports an "anabolic first" approach in patients found to be at very high risk of fracture, followed by maintenance therapy using an antiresorptive agent, and with the subsequent need for antiosteoporosis therapy addressed over a lifetime horizon.

[Artificial pancreas: where are we in 2020†?] / Pancréas artificiel†: où en sommes-nous en 2020†?

The artificial pancreas is a system coupling an automatic insulin infusion according to a continuous glucose monitoring. It is mainly intended for type 1 diabetic patients. Many advances in this area have led to the commercialization of so-called hybrid artificial pancreas devices. These devices always require human intervention to announce the amount of carbohydrates ingested at each meal. The complete fully automated system, called closed loop, is being evaluated thanks to the improvement of prediction algorithms. This paper aims to describe the progress of the artificial pancreas in 2020.

Le pancréas artificiel (PA) est un système couplant la perfusion automatique d'insuline en fonction de la concentration du glucose enregistrée de manière continue. Il s'adresse, principalement, aux patients diabétiques de type 1. Les nombreux progrès en la matière ont permis d'aboutir à la commercialisation de systèmes de PA dits hybrides. Ceux-ci nécessitent toujours une intervention humaine pour l'annonce de la quantité de glucides ingérés aux différents repas. La fermeture complète de la boucle aboutissant à un système autorégulé est en cours d'évaluation grâce à l'amélioration des algorithmes de prédiction. Cet article fait le point sur l'état d'avancement du PA en 2020.

[Continuous glucose monitoring in the management of diabetes†: state-of-the art and perspectives]. / Mesure continue du glucosedans la prise en charge du diabète†:état des lieux et perspectives.

Continuous glucose monitoring is a technique that allows near-continuous measurement of interstitial glucose concentration. Much progress has been made in this area. The management of certain diabetic patients, in particular type 1, has been considerably improved thanks to the use of this technique. Many pitfalls have been crossed to allow its commercialization. There is still a lot of progress to be made. A good knowledge of these new devices is necessary to understand their strengths and weaknesses. This article briefly discusses the state of the art in this area and the expected perspectives of this attractive but expensive technology that must meet the ever-increasing but legitimate expectations of diabetic patients.

La mesure continue du glucose est une technique permettant de mesurer de manière quasi continue la concentration de glucose interstitiel. De nombreux progrès ont été réalisés dans ce domaine. La prise en charge de certains patients diabétiques, en particulier de type 1, s'est vue considérablement améliorée grâce à l'utilisation de cette technique. Bien que certains écueils aient été franchis pour permettre sa commercialisation, des progrès doivent encore être réalisés. Une bonne connaissance de ces nouveaux dispositifs est nécessaire pour en appréhender leurs forces et leurs faiblesses. Cet article aborde brièvement l'état des lieux en la matière et les perspectives attendues de cette technologie séduisante, mais coûteuse, qui se doit de répondre aux attentes sans cesse grandissantes, mais légitimes, des patients diabétiques.

Continuous subcutaneous insulin infusion with short-acting insulin analogues or human regular insulin: efficacy, safety, quality of life, and cost-effectiveness.

Portable insulin infusion devices are effective and safe insulin delivery systems for managing diabetes mellitus, especially type 1 diabetes. Rapidly absorbed insulin analogues, such as insulin lispro or insulin aspart, may offer an advantage over regular human insulin for insulin pumps. Several open-label randomised crossover trials demonstrated that continuous subcutaneous insulin infusion (CSII) with insulin lispro provided a better control of postprandial hyperglycaemia and a slightly but significantly lower glycated haemoglobin level, with lower daily insulin requirement and similar or even less hypoglycaemic episodes. A CSII study comparing insulin lispro and insulin aspart demonstrated similar results with the two analogues, and better results than those with regular insulin. Because these analogues have a quicker onset and a shorter duration of action than regular insulin, one might expect an earlier and greater metabolic deterioration in case of CSII interruption, but a more rapid correction of metabolic abnormalities after insulin boluses when reactivating the pump. These expectations were confirmed in randomised protocols comparing the metabolic changes occurring during and after CSII interruption of various durations when the pump infused either insulin lispro or regular insulin. The extra cost resulting from the use of CSII and insulin analogues in diabetes management should be compensated for by better metabolic control and quality of life. In conclusion, CSII delivering fast-acting insulin analogues may be considered as one of the best methods to replace insulin in a physiological manner by mimicking meal and basal insulin requirements, without higher risk of hypoglycaemia or ketoacidosis in well-educated diabetic patients.