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ACTG Bone Study Group Established; More Bone Issues Need Attention
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From Jules Levin, NATAP
The AIDS Clinical Trials Group (ACTG) has established the "Bone Complications Working Group". It will have its first conference call soon. This is a direct result of the formation by me of an informal Bone Committee composed mainly of ACTG researchers in January 2008 and an educational bone symposium I arranged held at the June ACTG meeting in Washington DC.
Here is the stated purpose of the new ACTG committee:
Over the next several months, this working group has been charged with the following:
&183; Assess the state of the science with regard to bone complications of HIV disease and/or its therapies
-- Evaluate ongoing studies in the field χ2 Evaluate availability of data and specimens available from ACTG trials for NWCS/DACS
&183; Identify unanswered research questions
-- Develop potential strategies to answer those questions
SO WHERE ARE WE GOING FROM HERE:
Fractures cause premature death, studies show this and its a well accepted outcome. This first study showing fracture rates are higher in HIV than HIV-negatives was published several weeks ago by Steve Grinspoon et al in JCEM. Cohort studies report 65% osteopenia in HIV at the average age of 45 yrs, and rates of osteoporosis in these studies are 5% to 20%.
I feel very firmly that all patients should receive baseline (1) bone-dexas and continuing followup. There are (2) numerous risk factors for bone loss in HIV, we need to identify and characterize them much better. The standard risk factors for bone loss are of much higher prevalence in HIV compared to HIV-negatives and inlude low BMI, smoking, and alcohol use. But in HIV there appear to be additional risk factors including HIV. (3) There is a tremendous need to (4) educate doctors, clinicians, and patients about bone disease pathogenesis, screening, care and treatment. It appears that PPIs, SSRIs, and glitazones can cause bone loss but these drugs are used in HIV+ individuals, and the risk is not well known by clinicians. (5) There is research finding HIV dysregulates bone metabolism, but we clearly need to better characterize this. (6) Mitochondria is in bone cells so we need to examine the effect of certain nukes on bone loss in HIV. (7) There needs to be extensive discussion surrounding recommendations and guidelines for screening with bone-dexas in HIV. The test is inexpensive and easy to implement but there is limited insurance reimbursement and low utility in HIV, this MUST CHANGE. Currently, our guidelines support reimbursement for 3 CD4 counts and viral load tests per year. This is absurd considering we need to screen for bone loss. (8) We need to better understand when to treat bone loss in HIV. In the general population there are ongoing debates about whether to treat osteopenia or only osteoporosis, so we need to have discussions around treatment suggestions. (9) In HIV men appear to have higher rates of bone loss than women, which is the exact opposite outside of HIV, where men are mostly ignored regarding bone loss. (11) The effect of ART needs to be better characterized. (10) New York State and other states have HIV treatment guidelines. State committees need to begin to consider addressing this serious problem.
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