title: Interventions to prevent and treat corticosteroid-induced osteoporosis and prevent osteoporotic fractures in Duchenne muscular dystrophy.
abstract: Corticosteroid treatment is considered the 'gold standard' for Duchenne muscular dystrophy (DMD); however, it is also known to induce osteoporosis and thus increase the risk of vertebral fragility fractures. Good practice in the care of those with DMD requires prevention of these adverse effects. Treatments to increase bone mineral density include bisphosphonates and vitamin D and calcium supplements, and in adolescents with pubertal delay, testosterone. Bone health management is an important part of lifelong care for patients with DMD.
  
  
  
  To assess the effects of interventions to prevent or treat osteoporosis in children and adults with DMD taking long-term corticosteroids; to assess the effects of these interventions on the frequency of vertebral fragility fractures and long-bone fractures, and on quality of life; and to assess adverse events.
  
  
  
  On 12 September 2016, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL Plus to identify potentially eligible trials. We also searched the Web of Science ISI Proceedings (2001 to September 2016) and three clinical trials registries to identify unpublished studies and ongoing trials. We contacted correspondence authors of the included studies in the review to obtain information on unpublished studies or work in progress.
  
  
  
  We considered for inclusion in the review randomised controlled trials (RCTs) and quasi-RCTs involving any bone health intervention for corticosteroid-induced osteoporosis and fragility fractures in children, adolescents, and adults with a confirmed diagnosis of DMD. The interventions might have included oral and intravenous bisphosphonates, vitamin D supplements, calcium supplements, dietary calcium, testosterone, and weight-bearing activity.
  
  
  
  Two review authors independently assessed reports and selected potential studies for inclusion, following standard Cochrane methodology. We contacted study authors to obtain further information for clarification on published work, unpublished studies, and work in progress.
  
  
  
  We identified 18 potential studies, of which two, currently reported only as abstracts, met the inclusion criteria for this review. Too little information was available for us to present full results or adequately assess risk of bias. The participants were children aged five to 15 years with DMD, ambulant and non-ambulant. The interventions were risedronate versus no treatment in one trial (13 participants) and whole-body vibration versus a placebo device in the second (21 participants). Both studies reported improved bone mineral density with the active treatments, with no improvement in the control groups, but the abstracts did not compare treatment and control conditions. All children tolerated whole-body vibration treatment. No study provided information on adverse events. Two studies are ongoing: one investigating whole-body vibration, the other investigating zoledronic acid.
  
  
  
  We know of no high-quality evidence from RCTs to guide use of treatments to prevent or treat corticosteroid-induced osteoporosis and reduce the risk of fragility fractures in children and adults with DMD; only limited results from two trials reported in abstracts were available. We await formal trial reports. Findings from two ongoing relevant studies and two trials, for which only abstracts are available, will be important in future updates of this review.
authors.affiliation: Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Room 02.041, 2nd Floor, Mulhouse, Grosvenor Road, Belfast, Northern Ireland, UK, BT12 6BJ.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Bell
authors.affiliation: Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Room 02.041, 2nd Floor, Mulhouse, Grosvenor Road, Belfast, Northern Ireland, UK, BT12 6BJ.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Shields
authors.affiliation: GP Out of Hours Service, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK.
authors.forename: Janet
authors.initials: J
authors.lastname: Watters
authors.affiliation: Withers Orthopaedic Centre, Belfast Health and Social Care Trust, Musgrave Park Hospital, Royal Group of Hospitals,, Stockman's Lane, Belfast, Northern Ireland, UK.
authors.forename: Alistair
authors.initials: A
authors.lastname: Hamilton
authors.affiliation: Department of Care for the Eldery, Belfast Health and Social Care Trust, Florence Elliot Centre, Royal Victoria Hospital, Belfast, Northern Ireland, UK, BT12 6BA.
authors.forename: Timothy
authors.initials: T
authors.lastname: Beringer
authors.affiliation: Musgrave Park Hospital, Belfast Health and Social Care Trust, Belfast, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Elliott
authors.affiliation: MRC Centre for Neuromuscular Diseases and Dubowitz Neuromuscular Centre, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery and Great Ormond Street, PO Box 114, London, UK, WC1B 3BN.
authors.forename: Rosaline
authors.initials: R
authors.lastname: Quinlivan
authors.affiliation: Paediatric Neurology, Royal Belfast Hospital for Sick Children, 180 Falls Road, Belfast, UK, BT12 6BE.
authors.forename: Sandya
authors.initials: S
authors.lastname: Tirupathi
authors.affiliation: Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Room 02.041, 2nd Floor, Mulhouse, Grosvenor Road, Belfast, Northern Ireland, UK, BT12 6BJ.
authors.forename: Bronagh
authors.initials: B
authors.lastname: Blackwood
mesh_terms: D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000009:adverse effects; D015519:Bone Density / Q000187:drug effects; D050071:Bone Density Conservation Agents / Q000627:therapeutic use*; D002118:Calcium / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D004164:Diphosphonates / Q000627:therapeutic use; D006801:Humans; D007093:Imidazoles / Q000627:therapeutic use; D008297:Male; D020388:Muscular Dystrophy, Duchenne / Q000188:drug therapy*; D010024:Osteoporosis / Q000139:chemically induced / Q000150:complications / Q000188:drug therapy* / Q000517:prevention & control; D058866:Osteoporotic Fractures / Q000209:etiology / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic; D000068296:Risedronic Acid / Q000627:therapeutic use; D016103:Spinal Fractures / Q000209:etiology / Q000517:prevention & control*; D014732:Vibration / Q000627:therapeutic use*; D014807:Vitamin D / Q000627:therapeutic use; D016474:Weight-Bearing; D000077211:Zoledronic Acid
chemical_list: D000305:Adrenal Cortex Hormones; D050071:Bone Density Conservation Agents; D004164:Diphosphonates; D007093:Imidazoles; D014807:Vitamin D; D000077211:Zoledronic Acid; D000068296:Risedronic Acid; D002118:Calcium