RESUMEN
ABSTRACT Background. Patients with chronic hepatitis B virus (HBV) are often treated with nucleoside/nucleotide antiviral agents and metabolic bone toxicity is a possible concern. Objective. To determine the relationships between fibroblast growth factor 23 (FGF23), a phosphaturic hormone, bone mineral density (BMD), and bone biochemical abnormalities in these patients. Material and methods. This is a cross-sectional observational study comparing HBV-infected subjects treated for at least one year with tenofovir (TDF), lamuvidine (LVD), entacavir (ETV), or not treated (CON). Patients with abnormalities in either calcium (Ca), phosphate (PO4), intact parathyroid hormone (iPTH) or FGF23 were further evaluated with BMD by DXA. Results. No difference in liver enzymes or renal function seen among groups, but hypophosphatemia was seen in all groups with the highest incidence with TDF treatment (14%). FGF 23 levels were found to be elevated in 11.1% of TDF patients, 2.77% amongst controls. No elevations were found in the LVD or ETV groups. Among a subset of subjects (FGF23, PO4, and/or Ca abnormalities) who underwent further evaluation, 67% had insufficient 25-OH vitamin D, and 30% had elevated 24 h urinary Ca or PO4 excretion. No patients with FGF23 abnormalities had urine abnormalities. 40% had low DXA Z-score (<-2) at spine or hip but there was no difference between control and antiviral treatment groups and the mean FRAX score was 2.33% for major osteoporotic fractures and 0.29% for hip fracture. Conclusion. Abnormalities in bone metabolism, particularly involving vitamin D insufficiency, in HBV-treated subjects were observed with a small increased likelihood in TDF treated patients.
Asunto(s)
Humanos , Antivirales/uso terapéutico , Fosfatos/sangre , Huesos/efectos de los fármacos , Calcio/sangre , Lamivudine/uso terapéutico , Hepatitis B Crónica/tratamiento farmacológico , Factores de Crecimiento de Fibroblastos/sangre , Tenofovir/uso terapéutico , Guanina/análogos & derivados , Antivirales/efectos adversos , Factores de Tiempo , Deficiencia de Vitamina D/inducido químicamente , Huesos/metabolismo , Huesos/diagnóstico por imagen , Biomarcadores/sangre , Absorciometría de Fotón , Densidad Ósea/efectos de los fármacos , Estudios Transversales , Factores de Riesgo , Resultado del Tratamiento , Remodelación Ósea/efectos de los fármacos , Hepatitis B Crónica/diagnóstico , Hepatitis B Crónica/sangre , Fracturas Óseas/inducido químicamente , Tenofovir/efectos adversos , Guanina/efectos adversos , Guanina/uso terapéuticoRESUMEN
BACKGROUND: Patients with chronic hepatitis B virus (HBV) are often treated with nucleoside/nucleotide antiviral agents and metabolic bone toxicity is a possible concern. OBJECTIVE: To determine the relationships between fibroblast growth factor 23 (FGF23), a phosphaturic hormone, bone mineral density (BMD), and bone biochemical abnormalities in these patients. MATERIAL AND METHODS: This is a cross-sectional observational study comparing HBV-infected subjects treated for at least one year with tenofovir (TDF), lamuvidine (LVD), entacavir (ETV), or not treated (CON). Patients with abnormalities in either calcium (Ca), phosphate (PO4), intact parathyroid hormone (iPTH) or FGF23 were further evaluated with BMD by DXA. RESULTS: No difference in liver enzymes or renal function seen among groups, but hypophosphatemia was seen in all groups with the highest incidence with TDF-treatment (14%). FGF 23 levels were found to be elevated in 11.1% of TDF patients, 2.77% amongst controls. No elevations were found in the LVD or ETV groups. Among a subset of subjects (FGF23, PO4, and/or Ca abnormalities) who underwent further evaluation, 67% had insufficient 25-OH vitamin D, and 30% had elevated 24 h urinary Ca or PO4 excretion. No patients with FGF23 abnormalities had urine abnormalities. 40% had low DXA Z-score (<-2) at spine or hip but there was no difference between control and antiviral treatment groups and the mean FRAX score was 2.33% for major osteoporotic fractures and 0.29% for hip fracture. CONCLUSION: Abnormalities in bone metabolism, particularly involving vitamin D insufficiency, in HBV-treated subjects were observed with a small increased likelihood in TDF treated patients.
Asunto(s)
Antivirales/uso terapéutico , Huesos/efectos de los fármacos , Calcio/sangre , Factores de Crecimiento de Fibroblastos/sangre , Guanina/análogos & derivados , Hepatitis B Crónica/tratamiento farmacológico , Lamivudine/uso terapéutico , Fosfatos/sangre , Tenofovir/uso terapéutico , Absorciometría de Fotón , Adulto , Anciano , Antivirales/efectos adversos , Biomarcadores/sangre , Densidad Ósea/efectos de los fármacos , Remodelación Ósea/efectos de los fármacos , Huesos/diagnóstico por imagen , Huesos/metabolismo , Estudios Transversales , Femenino , Factor-23 de Crecimiento de Fibroblastos , Fracturas Óseas/inducido químicamente , Guanina/efectos adversos , Guanina/uso terapéutico , Hepatitis B Crónica/sangre , Hepatitis B Crónica/diagnóstico , Humanos , Lamivudine/efectos adversos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Tenofovir/efectos adversos , Factores de Tiempo , Resultado del Tratamiento , Deficiencia de Vitamina D/inducido químicamenteRESUMEN
BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a significant cause of morbidity and mortality for patients with COPD. AECOPD are the leading cause of hospital admissions in Canada. Although multiple guidelines have been developed for the acute and chronic management of COPD, there are few quality assurance studies investigating adherence to these guidelines. METHODS: A retrospective chart review of all patients admitted to a tertiary care hospital in 2009 for an AECOPD was performed. Using a standardized data abstraction tool, adherence to current guidelines across different physician groups and patient outcomes were assessed. Particular focus was centred on differences in management across physician groups. RESULTS: Overall, 293 patients were evaluated. Of these, 82.6% were treated with one or more chronic COPD medication(s) in the community, with only 17.7% of patients treated with a long-acting inhaled anticholinergic medication. For treatment of AECOPD, 58% of patients received corticosteroids and 84% received antibiotics. Compared with general medicine and the hospitalist service, the respiratory medicine service demonstrated significantly better adherence with current treatment guidelines; however, even this was less than optimal. In addition, there was poor follow-up of patients cared for outside of the respiratory service. CONCLUSIONS: The present study identified significant care gaps in the treatment of patients admitted with AECOPD and on their discharge.