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PubMed2000

Osteoporosis.

Osteoporosis is a disorder of decreased bone mass, microarchitectural deterioration, and fragility fractures. Osteoporosis is widespread and can affect people of all ethnic backgrounds and many older women and men. An essential element in preventing osteoporosis is the achievement of normal peak bone mass. Adequate nutrition, appropriate calcium and vitamin D intake, regular menstrual cycles and a well balanced exercise program of exercise are essential elements in achieving peak bone mass. At menopause women undergo accelerated bone loss. Thereafter, women and men gradually lose bone mass. A loss of one standard deviation give rise to an enhanced twofold risk of spine fractures or a 2.5 risk of hip fracture. Bone mass is determined by dual energy x-ray absorptiometry, quantitative computed tomography scan, and a peripheral ultrasound. Dual energy x-ray absorptiometry has outstanding precision (within 1% to 2%), and has the ability to show the efficacy of drug intervention. Peripheral measurements may identify osteoporosis but only have a 70% correlation with hip and spine bone mass. Dual energy x-ray absorptiometry determines bone mass in a patient but the bone collagen breakdown products (N-telopeptide crosslinks) establish the current rate of bone loss. Major risk factors leading to fragility fracture include low body weight, history of fracture, family history of osteoporosis, and smoking. All individuals should ingest adequate calcium and vitamin D, exercise, and prevent falls. Women with low bone mass, high urinary bone collagen breakdown products, and/or major risk factors should consider hormone replacement therapy or a selective estrogen receptor modulator (Evista), calcitonin and bisphosphonates (alendronate). These agents successfully increase bone mass and limit fracture risk. Men at risk for fragility fractures respond similarly as women to alendronate and calcitonin. Although vertebral compression fractures can occur spontaneously, hip fractures are attributable to low bone mass coupled with a fall. Hence, fall prevention programs in addition to medical treatment are critical in the prevention of fragility fractures.

Female↗
PubMed1992

Differential involvement of the dorsal and lumbar spine in osteoporosis.

The presence of normal bone density values in the lumbar spine is often assumed to exclude osteoporosis. Eleven cases are reported in which normal lumbar spine bone density and radiology were associated with one or more dorsal spine fractures; the diagnosis was postmenopausal osteoporosis in eight patients and corticosteroid induced osteoporosis in three. These findings suggest that spinal osteoporosis may sometimes be a focal disorder and emphasise the need for dorsal spine radiology in addition to bone densitometry in patients with strong risk factors for osteoporosis or with clinical evidence of the dorsal spine being affected.

Absorptiometry, Photon↗
PubMed2004

Vignettes in osteoporosis: a road map to successful therapeutics.

UNLABELLED: The diagnosis and management of osteoporosis have become increasingly more complex as new drugs enter the marketplace and meta-analyses of randomized trials with "other" agents become more prolific. We describe five common clinical scenarios encountered in the practice of osteoporosis medicine and various road maps that could lead to successful therapy. INTRODUCTION: The diagnosis and treatment of osteoporosis have changed dramatically in the last decade. Advances in diagnostic technologies and a range of newer treatment options have provided the clinician with a wide array of choices for treating this chronic disease. Despite the issuance of several "guidelines" and practice recommendations, there still remains confusion among clinicians about basic approaches to the management of osteoporosis. This paper should be used as a case-based approach to define optimal therapeutic choices. MATERIALS AND METHODS: Five representative cases were selected from two very large clinical practices (Bangor, ME; Pittsburgh, PA). Diagnostic modalities and treatment options used in these cases were selected on an evidence-based analysis of respective clinical trials. Subsequent to narrative choices by two metabolic bone disease specialists (SG and CR), calculation of future fracture risk and selection of potential alternative therapeutic regimens were reviewed and critiqued by an epidemiologist (DB). RESULTS: A narrative about each case and possible management choices for each of the five cases are presented with references to justify selection of the various therapeutic options. Alternatives are considered and discussed based on literature and references through July 2003. The disposition of the individual patient is noted at the end of each case. CONCLUSIONS: A case-based approach to the management of osteoporosis provides a useful interface between guidelines, evidence-based meta-analyses, and clinical practice dilemmas.

Aged↗
PubMed2000

Etridronate therapy in the treatment and prevention of osteoporosis.

Etidronate disodium is an oral bisphosphonate compound known to reduce bone resorption through the inhibition of osteoclastic activity. This article is a review of its efficacy and safety in the treatment and prevention of postmenopausal and corticosteroid-induced osteoporosis. In general, studies of cyclical etidronate therapy (400 mg daily for 2 wk every 3 mo) have found a significant improvement in bone density. These studies have not been powered to study fracture incidence, but a reduced fracture rate has been found in some of the studies reviewed. Studies examining cyclical etidronate in the prevention of osteoporosis indicate it prevents early menopausal bone loss and is free of significant side effects. In both prevention of corticosteroid-induced osteoporosis and treatment of patients who have been on long-term corticosteroid therapy, cyclical etidronate appears to increase bone density and prevent further loss of bone. In summary, a review of available literature pertaining to the use of etidronate in prevention and treatment of primary and secondary osteoporosis has been presented. This review suggests etidronate, used as a cyclical therapy, is a safe and effective therapy. The weight of evidence suggests it is capable of reducing fracture risk in patients with osteoporosis. Increases in bone density at the spine and hip are not as pronounced as with some other bisphosphonates, particularly alendronate, but no direct clinical comparison trials of significant size or duration have been undertaken.

Adrenal Cortex Hormones↗
PubMed2006

Biochemical markers of bone turnover in the clinical development of drugs for osteoporosis and metastatic bone disease: potential uses and pitfalls.

Biochemical markers of bone turnover are used increasingly during the clinical development of drugs for the treatment of metabolic bone diseases such as Paget's disease, osteoporosis and cancer that has metastasised to the bone. However, assessing the optimal value of these markers is often complicated, and such an assessment is an obvious prerequisite for rational use of the markers and, consequently, potential improvement of clinical drug development. Biochemical markers of bone turnover are substances in the blood or urine that are produced or released during bone remodelling. They provide semiquantitative information on bone remodelling, and are often the most adequate tool to describe the pharmacodynamics of the drug. Their use has increased considerably because of dose-effect relationships that have been seen with certain drugs, but also because they have proven relationships with clinical outcomes in several metabolic bone diseases. However, there is a lack of information on the kinetics of these markers, and the immunoassays that are frequently used in their monitoring often measure a mixture of fragments rather than a single molecular entity. For drug development it should also be realised that different markers, but also different assays for the same marker, may provide different results, considerably limiting the ability to compare results. In postmenopausal osteoporosis, relationships have been shown between several biochemical markers of bone turnover, and either fracture risk and/or the antifracture efficacy of drugs. Such relationships can be used for the development of drugs with similar mechanisms of action, but also for the development of these drugs for closely related indications, such as corticosteroid-induced osteoporosis. In both of these instances, data on effects on biochemical markers of bone turnover are usually employed in combination with information about effects on bone mineral density. However, the relationships of these parameters with clinical outcomes may be remarkably different for drugs with alternative mechanisms of action, challenging the use of the markers for the development of new drugs for the treatment of patients with osteoporosis. At present, the pharmacological treatment of cancer that has metastasised to the bone is limited to several bisphosphonates. Recent studies have shown relationships between the normalisation of levels of biochemical markers of bone turnover and clinical outcomes, and prospective studies investigating the application of such relationships are ongoing. The markers may play an important role in the optimisation of registered bisphosphonate treatments. However, their role in the development of new drugs is still limited to dose selection, and potential relationships with clinical outcomes remain to be investigated in instances of new mechanisms of action. Biochemical markers of bone turnover are a valuable asset for drug development, but their rational use is determined by a number of variables. Correctly manipulating these may improve clinical development of drugs for the treatment of patients with metabolic bone diseases such as osteoporosis and cancer metastatic to the bone.

Adrenal Cortex Hormones↗
PubMed2006

Anabolic Agents for Osteoporosis : What is Their Likely Place in Therapy?

Antiresorptive agents for osteoporosis are a cornerstone of therapy, but anabolic drugs have recently widened our therapeutic options. By directly stimulating bone formation, anabolic agents reduce fracture incidence by improving other bone qualities in addition to increasing bone mass. Teriparatide (human parathyroid hormone[1-34]) has clearly emerged as a major approach for selected patients with osteoporosis. Teriparatide increases bone mineral density and bone turnover, improves bone microarchitecture, and changes bone size. The incidence of vertebral and non-vertebral fractures is reduced. Teriparatide is approved in many countries throughout the world for the treatment of both postmenopausal women and men with osteoporosis who are at high risk for fracture. Another anabolic agent, strontium ranelate, may both promote bone formation and inhibit bone resorption. Clinical trials support the use of strontium ranelate as a treatment for postmenopausal osteoporosis and have shown that strontium ranelate reduces the frequency of vertebral and non-vertebral fractures. Other potential anabolic therapies for osteoporosis, including other forms of parathyroid hormone, growth hormone, and insulin-like growth factor-I, have been examined, although less data are currently available on these approaches.

Anabolic Agents↗
PubMed2002

Secondary causes of osteoporosis.

Secondary causes of bone loss are not often considered in patients who are diagnosed as having osteoporosis. In some studies, 20% to 30% of postmenopausal women and more than 50% of men with osteoporosis have a secondary cause. There are numerous causes of secondary bone loss, including adverse effects of drug therapy, endocrine disorders, eating disorders, immobilization, marrow-related disorders, disorders of the gastrointestinal or biliary tract, renal disease, and cancer. Patients who have undergone organ transplantation are also at increased risk for osteoporosis. In many cases, the adverse effects of osteoporosis are reversible with appropriate intervention. Because of the many treatment options that are now available for patients with osteoporosis and the tremendous advances that have been made in understanding the pathogenesis and diagnosis of the condition, it is important that medical disorders are recognized and appropriate interventions are undertaken. This article provides the framework for understanding causes of bone loss and approaches to their management.

Diabetes Mellitus, Type 1↗
PubMed2000

Evaluation of osteoporosis.

Osteoporosis is a silent epidemic that is preventable and treatable. Few people are currently having osteoporosis diagnosed early enough to receive the benefit of prevention. Therefore, most present with a fracture as the first clinical manifestation of the disease. The physician taking a history must have a high index of suspicion for osteoporosis. All women should be counseled about risk factors for osteoporosis. The diagnosis of this disease includes an evaluation of bone mineral density by radiologic technique. The osteopathic physician is uniquely well trained to recognize and diagnose osteoporosis.

Bone Density↗
PubMed2001

Corticosteroid induced osteoporosis. Guidelines for treatment.

BACKGROUND: Last year, Australian Family Physician published 'Guidelines for Management of Postmenopausal Osteoporosis', which were developed by Osteoporosis Australia. Recently, significant advances in our understanding of the treatment of corticosteroid osteoporosis have occurred. OBJECTIVE: The following guidelines, also developed by Osteoporosis Australia, and supported by the National Asthma Campaign, are to help general practitioners identify those patients at risk of this problem and to provide information about current treatment strategies. DISCUSSION: Corticosteroids are widely used and effective agents for the control of many inflammatory diseases. Corticosteroid osteoporosis is a common problem associated with the long term high dose use of these medications.

Adrenal Cortex Hormones↗
PubMed2001

Preventing and treating osteoporosis: strategies at the millennium.

Osteoporosis has been defined as "a progressive systemic disease characterized by low bone density and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture." Osteoporosis and the consequences of compromised bone strength--particularly vertebral and hip fractures--are a significant cause of frailty, and increased morbidity and even mortality and hence are a serious and costly public health problem in the elderly population. However, due to remarkable advances in basic and clinical research and in drug design, development, and testing, a number of efficacious, evidence-based options are available for the prevention and treatment of osteoporosis. These options extend far beyond estrogen/progestin therapy and include lifestyle and dietary changes such as increasing weight-bearing activity, enhancing calcium and vitamin D intake, as well as incorporating pharmacologic agents such as the bisphosphonates and selective estrogen receptor modulators (SERMs) such as raloxifene. In addition to its efficacy in increasing bone mineral density and reducing vertebral fractures by almost 40% in women with osteoporosis, the SERM raloxifene appears to promote a cardioprotective profile and to offer some protection against breast cancer. The potential of raloxifene to prevent or delay the development of a number of chronic diseases of aging such as osteoporosis, cardiovascular disease, and perhaps even Alzheimer's disease has stimulated the development and refinement of subsequent generations of SERMs aimed at maximizing beneficial effects in a wide variety of tissues while eliminating deleterious outcomes and side effects.

Diphosphonates↗
PubMed2002

Guidelines for the treatment of postmenopausal osteoporosis for general practitioners.

BACKGROUND: Osteoporosis Australia has been committed to the education of general practitioners and the community with a series of updated guidelines on the management of osteoporosis. Since the last series was published in Australian Family Physician (August 2000), there have been further advances in our understanding of the treatments involved in both prevention of bone loss and the management of established osteoporosis. OBJECTIVE: This article represents updated guidelines for the treatment of postmenopausal osteoporosis to assist GPs identify those women at risk and to review current treatment strategies. DISCUSSION: Osteoporosis and its associated problems are major health concerns in Australia, especially with an aging population. While important principles of management are still considered to be maximising peak bone mass and preventing postmenopausal bone loss, new clinical trial data about drugs such as the bisphosphonates, raloxifene and oestrogen have recently become available and the relative role of various agents is gradually becoming clearer. The use of long term hormone replacement therapy has mixed risks and benefits that requires individual patient counselling.

Australia↗
PubMed2004

Osteoporosis--diagnosis, treatment and management.

BACKGROUND: Osteoporosis is common, asymptomatic and usually undetected until a fracture occurs. Fracture, particularly hip fracture, can be associated with significant mortality, morbidity and loss of independence. OBJECTIVE: This article presents a practical case based approach to identify and manage osteoporosis. DISCUSSION: The major risk factors for osteoporosis in men and women are known, and case finding by dual X-ray absorptiometry and treatment with effective medications are subsidized by the commonwealth government. At the menopause, symptomatic women considering oestrogen replacement should assess their individual risk of osteoporosis, cardiovascular events and breast cancer. Men also develop osteoporosis and this should be on the health agenda along with cardiovascular disease, prostate and colon cancer, and diabetes. Treatment should include supplemental calcium and occasionally vitamin D. There is strong evidence for the benefits of bisphosphonates, the selective oestrogen receptor modulators and oestrogen replacement.

Aged↗
PubMed2004

Guidelines for the management of postmenopausal osteoporosis for GPs.

BACKGROUND: Since the last series of guidelines on the management of osteoporosis from Osteoporosis Australia was published in Australian Family Physician (October 2002), there have been further advances in our understanding of the treatment involved in both the prevention of bone loss and the management of established osteoporosis. OBJECTIVE: This article provides updated guidelines for the management of postmenopausal osteoporosis to assist general practitioners identify those women at risk, and reviews current treatment strategies. DISCUSSION: Osteoporosis and its associated problems are major health concerns in Australia, especially with an aging population. While important principles of management are still considered to be maximising peak bone mass and preventing postmenopausal bone loss, new clinical trial data about drugs such as the bisphosphonates, raloxifene and oestrogen have recently become available and the relative role of various agents is gradually becoming clearer. The use of long term hormone therapy has mixed risks and benefits that requires individual patient counselling.

Absorptiometry, Photon↗
PubMed1995

Office management of osteoporosis: a guide for the primary care provider.

Osteoporosis is greatly increasing in prevalence as the population ages. Postmenopausal women are at particularly high risk. I have reviewed the risk factors for osteoporosis, the office evaluation, laboratory and radiologic testing, and available treatment of osteoporosis. Adequate calcium and vitamin D intake is important in prevention and treatment. Estrogen replacement is the treatment of choice for the menopausal women who has or is at risk for osteoporosis, but several alternatives are available. These drugs prevent bone loss but cannot restore lost bone to any significant degree. Until effective means of restoring normal bone are discovered, increasing peak bone mass in adolescents and young women with the hope of preventing osteoporosis may be the most important intervention.

Adolescent↗
PubMed1996

[Risk of osteoporosis in women in 4 different occupational groups].

Primary osteoporosis is common, with significant sociomedical consequences. This paper studies the prevalence of risk factors and risk behavior for osteoporosis in women of four different occupational groups: housewives, blue collar workers, white collar workers/civil servants and farmers. We analyzed risk factors and risk behavior associated with osteoporosis in the scientific literature. The sample comprises 9,939 women. The data set is based on a health survey conducted in 79 selected rural communities of Styria (Austria) between 1989 and 1993. Sociodemographic data, lifestyle, health complaints, chronic conditions and utilization of preventive and treatment services were surveyed by means of standardized personal interviews. The results show that the women of the four occupational groups were subjected to very different stresses. White collar workers/civil servants had the lowest risk with regard to osteoporosis. Our results suggest that efficient intervention programs to prevent osteoporosis need to specifically focus on the different social life styles of women.

Adult↗
PubMed1996

Osteoporosis prevention and treatment.

Bone fragility resulting from osteoporosis places a significant percentage of elderly women and other patient groups at risk for bone fracture. Risk factors for osteoporosis include hypogonadal states (particularly menopause), smoking, low calcium intake, lack of weight-bearing exercise, family history and use of certain medications. Preventive strategies are based on achieving and maintaining optimal bone mass through diet, exercise, appropriate use of hormone replacement therapy and avoidance of adverse influences, particularly smoking and certain medications. Laboratory investigations are of limited use in the detection and assessment of osteoporosis, but new techniques may help physicians identify patients with accelerated bone metabolism. Currently, the most precise method of radiologically assessing osteoporosis is dual-energy x-ray absorptiometry. Many new agents for the treatment of osteoporosis are being examined. First-line therapies currently include alendronate and calcitonin. The choice of therapy must be individualized and combined with advice about nutrition and exercise, both to optimize bone density and to minimize the risk of trauma.

Absorptiometry, Photon↗
PubMed1997

Contribution of calcaneal ultrasonic assessment to the evaluation of postmenopausal and glucocorticoid-induced osteoporosis.

We evaluated ultrasound propagation through the calcaneus using the Achilles Lunar unit in patients with postmenopausal or glucocorticoid-induced osteoporosis. Speed of sound, broadband ultrasound attenuation and a combination of these two parameters called stiffness were determined. Reproducibility was 0.23%, 2.6%, and 2.6% for these three parameters, respectively. Bone mineral density measured at the spine and femoral neck by absorptiometry was significantly correlated with all three ultrasound parameters in the women with postmenopausal osteoporosis (n = 47) and in the controls (n = 42). In the patients with glucocorticoid-induced osteoporosis (n = 35), only speed of sound was significantly correlated with the bone mineral density measurements. Mean values in the subjects with postmenopausal osteoporosis and in their age-matched controls were 1473 +/- 27.2 m/sec versus 1500.6 +/- 29.6 m/sec for speed of sound, 95.3 +/- 9.6 dB/Mhz versus 105.7 +/- 10.1 dB/Mhz for broadband ultrasound attenuation, and 56.1 +/- 13.2 versus 70.9 +/- 14.1 for stiffness, indicating a significant difference (P < 0.01). Z scores were -0.91, -1.1, -0.93, -0.97, and -1.05 for bone mineral density at the spine, bone mineral density at the femoral neck, speed of sound, broadband ultrasound attenuation and stiffness, respectively. Receiver Operating Characteristic curves showed that there were no statistically significant differences between the ultrasound parameters at the calcaneus and the absorptiometry measurements at the spine and femoral neck. Mean values in glucocorticoid-treated patients and age-matched controls were 1480 +/- 26.9 m/sec versus 1505.1 +/- 30.3 m/sec for speed of sound, 99.2/-11.4 dB/Mhz versus 105.9 +/- -10.2 dB/Mhz for broadband ultrasound attenuation, and 60.7 +/- 14 versus 72.1/14.5 for stiffness, again indicating a significant difference (P < or = 0.01). Z scores were -0.55, -0.65, -0.8, -0.67, and -0.78 for bone mineral density at the spine, bone mineral density at the femoral neck, speed of sound, broadband ultrasound attenuation and stiffness, respectively. Our data suggest that ultrasound parameters measured at the calcaneus are useful for evaluating postmenopausal and glucocorticoid-induced osteoporosis.

Absorptiometry, Photon↗
PubMed1997

[Epidemiology of osteoporosis].

Osteoporosis is a systemic disease of the skeleton characterized by decreased bone mass and a disturbed microarchitecture of the bone. Its consequences is an increase in fracture risk. In women, the risk of experiencing an osteoporotic fracture once in life is twice as high (30-40%) as in men. In a model using population-based data, it is estimated that 54% of 50-year-old women present an osteoporotic fracture once in their remaining life. Typical osteoporotic fractures involve vertebral bodies, the proximal femur and the forearm. The number of fractures caused by osteoporosis is steadily increasing, due to greater life expectancy in particular. In addition, there is a secular increase in the incidence of fractures. In Switzerland, the number of fractures of the hip per year increased from 5,500 in 1980 to 9,800 in 1990 (VESKA data). The consequences of these fractures for the patients and their life quality and the direct and indirect effects on society are generally underestimated. Mortality and morbidity are both increased in comparison with unfractured persons of the same age. One of the most serious consequences of hip fractures is the loss of functional independence in the elderly; 10% of patients lose their functional independence after such fractures, and about 10% need to be placed in homes. Fractures of the waist lead to hospitalization in about 70% of patients aged over 85, and in many patients with forearm fractures algodystrophy occurs. Hip fractures are responsible for about 175,000 days in hospital per year for all Switzerland. Applied to all fractures caused by osteoporosis, this number may be much higher. Lack of epidemiological data, insufficient methods of investigation and the symptomless and silent development of osteoporosis in its beginnings have in many respects led to severe underestimation of this disease in the past. The extension of this growing worldwide health problem has only recently become apparent in Switzerland, essentially because of increasing life expectancy. The frequency of hip fractures is well documented in Switzerland and comparable with that in the US. It justifies in itself the development of a strategy for prevention and treatment. But because osteoporosis is a systemic disease of the skeleton, additional Swiss data on fractures other than that of the hip, such as vertebral and forearm fractures, would be of great interest, especially in the sector of ambulatory medicine.

Activities of Daily Living↗