Treatment patterns and long-term persistence with osteoporosis therapies in women with Medicare fee-for-service (FFS) coverage.

Osteoporosis, a chronic disease, requires long-term therapy. In Medicare-insured women, denosumab persistence was higher than oral bisphosphonate persistence over up to 3 years of follow-up. Longer-term persistence was higher among women who persisted in the first year of therapy. INTRODUCTION: Osteoporosis, a chronic, progressive disease, requires long-term therapy; this study assessed long-term persistence with anti-resorptive therapies in postmenopausal women. METHODS: This retrospective cohort study used administrative claims for women with data in the 100% Medicare osteoporosis sample who initiated (index date) denosumab, oral/intravenous (IV) bisphosphonate, or raloxifene between 2011 and 2014 and who had ≥ 1 year (zoledronic acid: 14 months) of pre-initiation medical/pharmacy coverage (baseline). Persistence was assessed from index date through end of continuous coverage, post-index evidence of censoring events (e.g., incident cancer), death, or end of study (December 31, 2015). RESULTS: The study included 318,419 oral bisphosphonate users (78% alendronate), 145,056 denosumab users, 48,066 IV bisphosphonate users, and 31,400 raloxifene users; mean age ranged from 75.5 years (raloxifene) to 78.5 years (denosumab). In women with at least 36 months of follow-up (denosumab N = 25,107; oral bisphosphonates N = 79,710), more denosumab than oral bisphosphonate initiators were persistent at 1 year (73% vs. 39%), 2 years (50% vs. 25%), and 3 years (38% vs. 17%). Persistence decreased over time for all treatment groups, with denosumab users having the highest persistence in every follow-up time interval at or after 18 months. Women using denosumab, oral bisphosphonates, or raloxifene who persisted in a given year were more likely to remain persistent through the subsequent year. CONCLUSIONS: Denosumab users persisted longer with therapy than women using other anti-resorptive medications, including oral bisphosphonates. Early persistence may predict long-term persistence. Overall persistence with osteoporosis medications is suboptimal and may impact fracture risk. Efforts to improve first year persistence are needed.

The osteoporosis treatment gap in patients at risk of fracture in European primary care: a multi-country cross-sectional observational study.

This study in 8 countries across Europe found that about 75% of elderly women seen in primary care who were at high risk of osteoporosis-related fractures were not receiving appropriate medication. Lack of osteoporosis diagnosis appeared to be an important contributing factor. INTRODUCTION: Treatment rates in osteoporosis are documented to be low. We wished to assess the osteoporosis treatment gap in women ≥ 70 years in routine primary care across Europe. METHODS: This cross-sectional observational study in 8 European countries collected data from women 70 years or older visiting their general practitioner. The primary outcome was treatment gap: the proportion who were not receiving any osteoporosis medication among those at increased risk of fragility fracture (using history of fracture, 10-year probability of fracture above country-specific Fracture Risk Assessment Tool [FRAX] thresholds, T-score ≤ - 2.5). RESULTS: Median 10-year probability of fracture (without bone mineral density [BMD]) for the 3798 enrolled patients was 7.2% (hip) and 16.6% (major osteoporotic). Overall, 2077 women (55%) met one or more definitions for increased risk of fragility fracture: 1200 had a prior fracture, 1814 exceeded the FRAX threshold, and 318 had a T-score ≤ - 2.5 (only 944 received a dual-energy x-ray absorptiometry [DXA] scan). In those at increased fracture risk, the median 10-year probability of hip and major osteoporotic fracture was 11.2% and 22.8%, vs 4.1% and 11.5% in those deemed not at risk. An osteoporosis diagnosis was recorded in 804 patients (21.2%); most (79.7%) of these were at increased fracture risk. The treatment gap was 74.6%, varying from 53% in Ireland to 91% in Germany. Patients with an osteoporosis diagnosis were found to have a lower treatment gap than those without a diagnosis, with an absolute reduction of 63%. CONCLUSIONS: There is a large treatment gap in women aged ≥ 70 years at increased risk of fragility fracture in routine primary care across Europe. The gap appears to be related to a low rate of osteoporosis diagnosis.

Cost-effectiveness of pharmacological fracture prevention for osteoporosis as prescribed in clinical practice in France, Germany, Italy, Spain, and the United Kingdom.

This study estimated the cost-effectiveness of pharmacological fracture prevention as prescribed in the five largest European countries (EU5) using the IOF reference cost-effectiveness model. Pharmacological fracture prevention as prescribed in clinical practice was cost-saving (provided more QALYs at lower costs) compared to no treatment in each of the EU5. PURPOSE: To estimate the real-world cost-effectiveness of pharmacological fracture prevention as prescribed in the five largest European countries by population size: France, Germany, Italy, Spain, and the United Kingdom (UK) (collectively EU5). MATERIALS AND METHODS: We analyzed sales data on osteoporosis drugs in each of the EU5 to derive a hypothetical intervention that corresponds to the mix of osteoporosis medication prescribed in clinical practice. The costs for this treatment mix were obtained directly from the sales data, and the efficacy of the treatment mix was estimated by weighing the treatment-specific fracture risk reductions from a published meta-analysis. Subsequently, we estimated the cost-effectiveness using costs per quality adjusted life year (QALY) of the intervention compared to no treatment in each of the EU5 using the International Osteoporosis Foundation (IOF) reference cost-effectiveness model. The model population comprised postmenopausal women, mean age 72 years with established osteoporosis (T-score ≤ - 2.5) among whom 23.6% had a prevalent vertebral fracture. The model was populated with country-specific data from the literature. RESULTS: Pharmacological fracture prevention as prescribed in clinical practice was cost-saving (provided more QALYs at lower costs) compared to no treatment in each country. The findings were robust in scenario analyses. CONCLUSIONS: Pharmacological fracture prevention as prescribed in clinical practice is cost-saving in each of the EU5. Because of the under-diagnosis and under-treatment of post-menopausal osteoporosis, from a health economic perspective, further cost-savings may be reached by expanding treatment to those at increased risk of fracture currently not receiving any treatment.

Mdmx stabilizes p53 and Mdm2 via two distinct mechanisms.

The p53 protein maintains genomic integrity through its ability to induce cell cycle arrest or apoptosis in response to various forms of stress. Substantial regulation of p53 activity occurs at the level of protein stability, largely determined by the activity of the Mdm2 protein. Mdm2 targets both p53 and itself for ubiquitylation and subsequent proteasomal degradation by acting as an ubiquitin ligase, a function that needs an intact Mdm2 RING finger. For efficient degradation of p53 nuclear export appears to be required. The Mdmx protein, structurally homologous to Mdm2, does not target p53 for degradation, but even stabilizes both p53 and Mdm2, an activity most likely mediated by heterodimerization of the RING fingers of Mdm2 and Mdmx. Here we show that Mdmx expression leads to accumulation of ubiquitylated, nuclear p53 but does not significantly affect the Mdm2-mediated ubiquitylation of p53. In contrast, Mdmx stabilizes Mdm2 by inhibiting its self-ubiquitylation.

Aberrant expression of HDMX proteins in tumor cells correlates with wild-type p53.

It has been shown that the Hdmx gene is amplified in a subset of gliomas, but thus far, no data are available on HDMX protein expression in tumor cells. We now report that a significant fraction of tumor cell lines expresses increased HDMX levels compared with normal cells; in general, HDMX expression in these tumor cell lines correlates with the presence of wild-type p53. Analysis of tumor material showed that high HDMX expression is not a result of cell line establishment. Interestingly, several cell lines express alternative, shorter HDMX proteins. These results suggest that deregulated expression of HDMX plays a role in carcinogenesis as an alternative way to inactivate p53.

Hdmx stabilizes Mdm2 and p53.

The Mdm2 protein is a key regulator of p53 activity and stability. Upon binding, Mdm2 inhibits the transcription regulatory activity of p53 and promotes its rapid degradation. In this study we investigated the effect of the human Mdm2 homologue Hdmx on p53 stability. We found that Hdmx does not target p53 for degradation, although, like Mdm2, it inhibits p53-mediated transcription activation. On the contrary, Hdmx was found to counteract the degradation of p53 by Mdm2, and to stabilize both p53 and Mdm2. The RING finger of Hdmx was found to be necessary and sufficient for this stabilization, and it probably involves hetero-oligomerization with the RING finger of Mdm2, which may lead to inhibition of Mdm2's ubiquitin ligase activity. However, Hdmx does not relieve the inhibition by Mdm2 of transcription activation by p53, probably due to the formation of a trimeric complex consisting of Hdmx, Mdm2, and p53. We propose a model in which Hdmx secures a pool of largely inactive p53, which, upon the induction of stress, can be quickly activated.

Influence of Duraflo II heparin-treated extracorporeal circuits on the systemic inflammatory response in patients having coronary bypass.

Cardiopulmonary bypass generates a systemic inflammatory response, including the activation of leukocytes, contributing to postoperative morbidity. To evaluate whether the use of heparin-treated extracorporeal circuits could reduce the inflammatory reaction in patients undergoing cardiopulmonary bypass, we conducted a prospective clinical study on 14 patients having coronary artery bypass in whom perfusion was done randomly with either Duraflo II heparin-treated circuits or with nontreated circuits. In both groups systemic heparinization was performed before cardiopulmonary bypass. The use of heparin-treated circuits resulted in a reduction of systemic inflammatory activation during cardiopulmonary bypass. This was reflected by lower plasma levels of soluble tumor necrosis factor receptors (p < 0.05) and of interleukin-6 and interleukin-8 (p < 0.05), manifest after release of the aortic crossclamp. Furthermore, 6 and 12 hours after aortic crossclamp release significantly lower levels of the soluble E-selectin (p < 0.05) were observed in the Duraflo II group. In patients in whom noncoated circuits were used, a significant decrease in circulating soluble intercellular adhesion molecule 1 (p < 0.05) was found early during bypass. All these observations suggest that the use of a heparin-treated extracorporeal circuit reduces the systemic inflammatory activation and may after the leukocyte-endothelium interaction.

Lymphoma-associated translocation t(14;18) in blood B cells of normal individuals.

Successive oncogenic steps are necessary to generate cancer. In many B-cell lymphomas, chromosomal translocations are considered to be an early oncogenic hit. We investigated whether the lymphoma-associated t(14;18) involving the BCL2 oncogene can occur outside the context of malignancy. To this end, we extensively screened blood cells from healthy blood donors by a very sensitive seminested polymerase chain reaction (PCR) for breakpoint junctions at JH1-5 on 14q32 and the major breakpoint region of BCL2 on 18q21. In each individual, mononuclear cells, granulocytes, flow-sorted B cells, and T cells were separately tested in five to seven independently performed PCRs (in total, 0.5 x 10(6) to 1.0 x 10(6) cells per fraction per individual). Amplification products that hybridized with an internal BCL2 probe and a JH probe were sequenced. Six of nine individuals harbored t(14;18) breakpoints. Translocations were restricted to B cells, with an estimated frequency of 1 in 10(5) or less circulating B cells. In total, 23 of 51 experiments on B cells were positive in contrast to 1 of 48 on T cells and 2 of 47 experiments on granulocytes. Consistent with the presence of 4.7% to 13.0% B cells in the mononuclear cell fractions, only very few (4 of 47) tests were positive in these fractions. Sequence analysis showed that four of six individuals harbored two to five unrelated t(14;18)-carrying B-cell clones. All breakpoints had a structure similar to that in follicular lymphoma. We propose that B cells with the t(14;18) translocation are regularly generated in normal individuals, but that only very few cells with the translocation will acquire the additional oncogenic hits necessary to establish the malignant phenotype.

The involvement of Kupffer cells and liver endothelial cells in the clearance of large sized soluble IgA aggregates in rats.

These findings suggests that AIgA is bound both by KC and EC in normal situations. Because of the great phagocytic capacity of KC, the contribution of EC in handling AIgA in normal rats is minimal. However, when KC are defect or absent (as after Cl2MDP treatment), the handling of AIgA by EC may become of mayor importance, i.e. it will take over the phagocytic function of KC. Studies concerning a possible receptor on EC involved in binding of AIgA are in progress.

Differential regulatory effects of adenosine on cytokine release by activated human monocytes.

Adenosine is an endogenous nucleoside that can modulate the function of cells involved in the inflammatory response, such as polymorphonuclear leukocytes (PMN) and monocytes. Production and release of cytokines by activated mononuclear phagocytes is an important event in the pathogenesis of ischemia-reperfusion injury, a pathologic phenomenon that is associated with excessive ATP catabolism and subsequent local release of adenosine. The "retaliatory" metabolite adenosine has been shown to interfere with PMN function, thereby attenuating the deleterious consequences of ischemia and reperfusion. In this study, we demonstrate that adenosine inhibits the production of TNF-alpha, IL-6, and IL-8 by LPS-activated human monocytes with a differential potency. The A2 receptor-specific adenosine analogues 2-chloroadenosine and 5'-N-ethylcarboxamidoadenosine (NECA) were most effective in attenuating LPS-induced cytokine production, whereas the A1-selective adenosine analogue N6-cyclopentyladenosine (CPA) was less effective, indicating that inhibition of cytokine production by adenosine is primarily an A2 receptor-mediated event. The observed inhibitory effects were not restricted to endotoxin-induced cytokine production, because adenosine also inhibited TNF-alpha production by monocytes stimulated with the proinflammatory cytokine IL-1 beta. Again, 2-chloroadenosine and NECA reduced IL-beta-induced TNF-alpha production more potently than CPA. In contrast, adenosine enhanced production of IL-6 and IL-8 by monocytes stimulated with IL-1 beta. Furthermore, only 2-chloroadenosine, but not NECA, strongly inhibited cytokine-induced IL-6 and IL-8 production. These results suggest an additional A2 receptor-mediated mechanism of retaliatory action of adenosine under pathologic conditions where cytokine production by activated mononuclear phagocytes is involved, such as ischemia-reperfusion injury and septic shock.

Hereditary C6 deficiency in a strain of PVG/c rats.

A chance observation has led to the discovery of a strain of PVG rats (PVG/c-) which are deficient in complement (C) component C6. Analysis of total haemolytic activity (CH50) of PVG/c- serum revealed an absent CH50 activity compared with serum of other rat strains and of a PVG/c rat (PVG/c+) that showed normal C activity. Thus, the PVG/c- rat was unable to activate the C5b-9 membrane attack complex. To gain insight into the complement abnormalities, analysis of individual C components was performed. Testing the PVG/c- serum in a C6 haemolytic assay and using deficient human sera showed a deficiency of C6 in the PVG/c- rat. Highly purified human C6 and human sera deficient in other components were able to reconstitute the CH50 activity of the PVG/c- rat. The possibility that an inactivator of C was present in PVG/c- serum was excluded. The deficiency was found to be inheritable and under the control of an autosomal recessive gene. Furthermore, tissue antigens and immunity of the PVG/c- rat were found to be identical to those determined in the PVG/c+ rat. With regard to their health status, the PVG/c- animals seem to have no disadvantages compared with PVG/c+ rats when held under the same conditions within the protected environment of animal facilities. Taken together, both rat strains provide an unique animal model for studying the biological role of C, particularly the C5b-9 membrane attack complex in experimental medicine.

Complement depletion abolishes IgA-mediated glomerular inflammation in rats.

Recently, we developed an acute model for IgA-mediated glomerular inflammation in rats in which it was shown that polymeric (p) but not monomeric (m) IgA-containing immune complexes induce acute glomerular inflammation. The glomerular IgA-mediated inflammation is characterized by the activation of complement (C), the presence of intraglomerular macrophages and proteinuria. In the present study, we investigated the role of C in this IgA-mediated nephritis. Rats were pretreated either with cobra venom factor (CVF) to deplete them of circulating C3 or with phosphate-buffered saline followed by introduction of mesangial IgA deposits. Upon deposition of pIgA in the mesangial area, acute proteinuria was observed only in normocomplementemic rats and not in C-depleted animals. Immunofluorescent analysis revealed deposition of C3 and C9 in a pattern identical to that of IgA in the glomeruli of normal rats. Rats pretreated with CVF displayed clear mesangial deposition of IgA in the absence of C3 and C9. In none of the two groups were C4 deposits seen, indicating activation of C via the alternative pathway. In normocomplementemic animals, deposition of IgA together with C3 was associated with an influx of macrophages at day 2. C-depleted rats receiving pIgA also showed an influx of macrophages at 24 h following CVF administration and 1 and 2 days after IgA injection. However, no proteinuria was seen. To obtain insight into the mechanism of macrophage influx in the CVF-treated rats, we also analyzed the number of intraglomerular macrophages in rats receiving only CVF, without introduction of mesangial IgA deposits.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of liver endothelial and Kupffer cells in clearance of human C1q in rats.

In the present study the contribution of rat liver endothelial cells (EC) and Kupffer cells (KC) in the clearance of human (hu) C1q in rats was investigated. In untreated rats and rats depleted from KC the clearance kinetics and the tissue distribution of hu C1q were measured. In untreated rats, the clearance of hu C1q occurred in a monophasic manner with a half-life of 66 +/- 26.7 min. The clearance of hu C1q in KC-depleted rats was delayed significantly (p < 0.001) and occurred with a half-life of 217 +/- 78.8 min. Fifteen min after injection, 11 +/- 3.5% of hu C1q was found in the liver of untreated rats and 8 +/- 1.4% was found in the liver of KC-depleted rats. The percentage non-trichloroacetic acid precipitable activity in the circulation, as a measure for degradation of C1q, reached a level of 11.6 +/- 5.6% at 240 min in untreated rats compared with 4.6 +/- 5.8% in KC-depleted rats. Double immunofluorescence staining 5 min after administration of C1q in untreated rats, revealed that C1q was associated with KC and EC in the liver. Fifteen minutes after i.v. injection of hu C1q, there was an uptake of C1q in the hepatocytes. In KC-depleted rats, 5 min after administration of hu C1q, C1q was bound to the EC. Fifteen minutes after injection, C1q was also found in the hepatocytes. Electron microscopical studies revealed that C1q binds to EC, and that it is internalized in the hepatocytes and KC. The clearance of hu C1q in untreated rats was inhibited by preadministration of high concentrations of bovine C1q. These data show that rats depleted from KC are able to bind, internalize and degrade C1q, and that EC may play a role in the handling of C1q and C1q bound to immune complexes.

Detection of the t(14;18) translocation in frozen and formalin-fixed tissue.

As part of a retrospective study into the prevalence of the t(14;18) translocation in B-cell lymphomas, we assessed the suitability of the polymerase chain reaction (PCR) to amplify the t(14;18) major breakpoint region (MBR) in frozen and formalin-fixed tissue. Considering Southern blotting as a standard, the sensitivity of PCR was 81%. Of the various procedures used to extract DNA from paraffin-embedded tissue (PET), proteinase K digestion in the presence of nonionic detergents gave the highest yield and quality of DNA and the most efficient amplification rate. Using this method, excellent amplification rates (100%) were obtained for both the beta-globin control sequence and the MBR t(14;18) for fixed follicular lymphoma specimens collected in the previous 2 to 6 years (n = 27). Of nine older PETs, PCR on six gave inconsistent results, probably because of the poorer-quality substrate used for amplification. Specimens exposed to formol sublimate or formalin-acetic acid-alcohol were as suitable for amplification as tissues fixed in neutral-buffered formalin. The overall incidence of the MBR t(14;18) in all follicular lymphoma specimens as detected by both Southern blotting and PCR was 59% (23 of 39).

An acute model for IgA-mediated glomerular inflammation in rats induced by monoclonal polymeric rat IgA antibodies.

An acute model for IgA-mediated glomerular inflammation in rats was induced by the in situ deposition of IgA directly into the glomerular mesangium. F(ab')2 anti-Thy1 MoAb was used to anchor an antigen, DNP (2,4-dinitrophenol), in the glomeruli of rats. Subsequent infusion of rat polymeric (p-) or monomeric (m-) IgA MoAb with specificity for DNP resulted in mesangial deposition of IgA in both groups of rats. However, acute proteinuria was observed only in p-IgA-treated rats and not in PBS- or m-IgA-treated rats. Immunofluorescence analysis revealed deposition of C3 in an identical pattern to that of IgA in the glomeruli of p-IgA-treated rats. No mesangial deposits of C4 or C1q were seen in these animals. Rats receiving m-IgA or PBS displayed no detectable C3, C4 or C1q deposition. The amount of proteinuria in p-IgA-treated rats was related to the amount of deposited C3. The presence of intraglomerular monocytes was only observed 2 days after p-IgA injection. By light microscopy, aneurysm formation, mesangial hypercellularity and matrix expansion were seen only in p-IgA-treated rats. However, by 37 days post-injection complete resolution of the lesions was observed. No histological renal changes were observed in PBS- or m-IgA-treated rats. In conclusion, an acute form of IgA-mediated nephritis in rats was induced by p-IgA but not by m-IgA. This reproducible model provides a basis for further study into the mechanisms of IgA-mediated glomerular inflammation.

In vivo activation of complement by IgA in a rat model.

In this study we investigated the capacity of rat IgA to activate complement (C) in vivo in a rat model. Rat monomeric (m-), dimeric (d-) and polymeric (p-) IgA MoAbs were injected intravenously and assessed for deposition of C3 and C4 on IgA. By ELISA it was shown that both d- and p-IgA bound C3 whereas no binding of C3 by m-IgA was observed. Polymeric IgA was more efficient in binding of C3 as compared with d-IgA. However, in haemolytic assays no consistent decrease of plasma complement levels was observed except for dimeric IgA which induced a marginal consumption of AP50. When rats were pre-treated with cobra venom factor (CVF) to deplete C3, no C3 deposition was found on m-, d- or p-IgA. Neither m- nor d- or p-IgA was able to bind C4 in vivo. In agreement with the results described above, large sized polymeric IgA was shown to be taken up by Kupffer cells (KC) together with C3. No C3 was detected when rats were depleted of C using CVF. Taken together, the experimental data suggest that d- and p-IgA are able to activate C via the alternative pathway in vivo.

Kupffer cell depletion in vivo results in preferential elimination of IgG aggregates and immune complexes via specific Fc receptors on rat liver endothelial cells.

In the present study we have investigated the clearance kinetics and tissue distribution of monomeric (m) IgG and soluble aggregates of IgG (AIgG) and immune complexes (IC) in normal and Kupffer cell (KC) depleted rats. In normal rats, clearance of mIgG occurred in a biphasic manner with a first half-life (T1/2) (T1) of 36.3 +/- 6.3 min and a second T1/2 (T2) of 168.4 +/- 4.7 min. AIgG composed of 20-27 IgG molecules per aggregate were cleared significantly faster than mIgG with a T1 of 2.5 +/- 0.1 min and a T2 of 32.5 +/- 5.6 min. KC depletion did not have a significant effect on the clearance rate of mIgG (T1: 33.4 +/- 8.9 min; T2; 159.5 +/- 12.5 min), while clearance of AIgG was delayed significantly with T1 4.8 +/- 0.7 min and T2 41.2 +/- 3.2 min. Eight minutes after injection, 77% of AIgG was found in the liver in normal rats while 62% was found in the liver of KC-depleted rats. Double immunofluorescence studies indicated that AIgG in the liver was associated with KC and endothelial cells (EC) in normal rats. In KC-depleted rats, AIgG was strongly associated with EC. A similar staining pattern was observed when IgG-immune IC were administered. The clearance of AIgG in KC-depleted rats was inhibited fully by pre-administration of high concentrations of IgG but not by pretreatment with IgA. asialofetuin (ASFe) or ovalbumin (OVA). Aggregated F(ab')2IgG was cleared with a comparable rate to mIgG from the circulation, again suggesting Fc gamma receptor-mediated elimination of AIgG by EC. There was a reduced degradation of AIgG in rats depleted of KC as compared with normal rats. These data suggest binding and degradation of AIgG by EC in vivo.