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Part 2: When Should Bisphosphonates Be Used in Children with Chronic Illness Osteoporosis?

  • Pediatrics (C Munns and F Rauch, Section Editors)
  • Published:
Current Osteoporosis Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Part 1 of this review on secondary osteoporosis of childhood was devoted to understanding which children should undergo bone health monitoring, when to label a child with osteoporosis in this setting, and how best to monitor in order to identify early, rather than late, signs of bone fragility. In Part 2 of this review, we discuss the next critical step in deciding which children require bisphosphonate therapy. This involves distinguishing which children have the potential to undergo “medication-unassisted” recovery from secondary osteoporosis, obviating the need for bisphosphonate administration, from those who require anti-resorptive therapy in order to recover from osteoporosis.

Recent Findings

Unlike children with primary osteoporosis such as osteogenesis imperfecta, where the potential for recovery from osteoporosis without medical therapy is limited, many children with secondary osteoporosis can undergo complete recovery in the absence of bisphosphonate intervention. Over the last decade, natural history studies have unveiled the spectrum of this recovery, which spans overt deterioration (i.e., incident vertebral and non-vertebral fractures and declines in bone mineral density (BMD)), to spectacular reclamation of BMD, and complete restoration of normal vertebral dimensions after spine fractures. The fact that reshaping of vertebral bodies following fractures is growth-dependent underscores the need to identify and treat those at risk for permanent vertebral deformity in a timely fashion.

Summary

The decision to treat a child with a bisphosphonate hinges on distinguishing bone fragility from typical childhood fractures, and determining the potential for medication-unassisted recovery following an osteoporotic fragility fracture. While improvements in BMD are a well-known sign of recovery, restitution of bone structure is also a key indicator of recuperation, one that is unique to childhood, and that plays a pivotal role in the decision to intervene or not.

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Abbreviations

BMD:

Bone mineral density

DMD:

Duchenne muscular dystrophy

GC:

Glucocorticoid(s)

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Acknowledgements

Dr. Ward would like to thank the research staff and scientists affiliated with The Ottawa Pediatric Bone Health Research Group and The CHEO Genetic and Metabolic Bone Disease Clinic who have been dedicated to the study and care of children with osteoporosis for many years, including Maya Scharke, Elizabeth Sykes, Lynn MacLeay, Scott Walker, Colleen Hartigan, members of the Canadian STeroid-induced Osteoporosis in the Pediatric Population (STOPP) Consortium, and Drs. Kerry Siminoski, Frank Rauch, Marie-Eve Robinson, Karine Khatchadourian, Jacob Jaremko, Nazih Shenouda, Mary-Ann Matzinger, Khaldoun Koujok, Jinhui Ma, Stefan Jackowski, Nasrin Khan, and Victor Konji.

Funding

Dr. Ward has been supported by Tier 1 and Tier 2 Research Chair Awards from the University of Ottawa since 2010, the Children’s Hospital of Eastern Ontario Departments of Pediatrics and Surgery, and the Children’s Hospital of Eastern Ontario Research Institute. The STeroid-induced Osteoporosis in the Pediatric Population (STOPP) study was funded by the Canadian Institutes of Health Research (Funding Reference Number 64285).

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Authors and Affiliations

  1. University of Ottawa, Ottawa, Canada

    Leanne M. Ward

  2. The Ottawa Pediatric Bone Health Research Group, The CHEO Pediatric Genetic and Metabolic Bone Disease Clinic, The Children’s Hospital of Eastern Ontario (CHEO), Room 250H, 401 Smyth Road, Ottawa, Ontario, K1H 8L1, Canada

    Leanne M. Ward

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Correspondence to Leanne M. Ward.

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Conflict of Interest

Dr. Ward has participated in clinical trials with ReveraGen BioPharma, PTC Therapeutics, Catabasis Pharmaceuticals, Novartis, and Amgen. Dr. Ward has also received consulting fees from PTC Therapeutics, Novartis, and Amgen, with funds to the Children’s Hospital of Eastern Ontario Research Institute.

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This article does not contain any original studies with human or animal subjects performed by the author.

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Ward, L.M. Part 2: When Should Bisphosphonates Be Used in Children with Chronic Illness Osteoporosis?. Curr Osteoporos Rep 19, 289–297 (2021). https://doi.org/10.1007/s11914-021-00672-0

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