Yield of laboratory testing to identify secondary contributors to osteoporosis in otherwise healthy women

Risk of fracture in urolithiasis: a population-based cohort study using the health improvement network

BACKGROUND AND OBJECTIVES

Studies have shown decreased bone mineral density in individuals with urolithiasis, but their burden of fracture remains unclear. This study sought to determine whether urolithiasis is associated with increased fracture risk across the lifespan and to delineate sex effects.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A population-based retrospective cohort study using The Health Improvement Network was performed. The median calendar year for the start of the observation period was 2004 (1994-2012). This study identified 51,785 participants with ≥1 of 87 diagnostic codes for urolithiasis and 517,267 randomly selected age-, sex-, and practice-matched participants. Cox regression was used to estimate the hazard ratio (HR) for first fracture. Fractures identified using diagnostic codes were classified by anatomic site.

RESULTS

Median age was 53 years, and 67% of participants were men, confirming their greater urolithiasis burden. Median time from urolithiasis diagnosis to fracture was 10 years. The HR for fracture associated with urolithiasis differed by sex and age (P for interactions, P≤0.003). In men, the adjusted HR was greatest in adolescence (1.55; 95% confidence interval [95% CI], 1.07 to 2.25) with an overall HR of 1.10 (95% CI, 1.05 to 1.16). Urolithiasis was associated with higher fracture risk in women aged 30-79 years (HR, 1.17-1.52), and was highest in women aged 30-39 years (HR, 1.52; 95% CI, 1.23 to 1.87). Peak background fracture rates were highest in boys aged 10-19 years and in women aged 70-79 years. The incidence per 10,000 person-years in participants with versus without urolithiasis was 392 versus 258 in male participants aged 10-19 years, and 263 versus 218 in women aged 70-79 years. Distribution of fracture site within sex did not differ between participants with versus without urolithiasis.

CONCLUSIONS

Urolithiasis was associated with higher incident fracture risk. The significantly higher risk at times of peak background fracture incidence in adolescent boys and elderly women has profound public health implications.

The burden of osteoporosis in Brazil

Osteoporotic fractures impose severe physical, psychosocial, and financial burden both to the patient and the society. Studies on the prevalence of osteoporosis and fragility fractures in Brazil show a wide variation, due to differences in sample size, the population studied, and methodologies. Few studies have been conducted in Brazil about the cost-effectiveness analyses of different intervention options aimed at the diagnosis and treatment of osteoporosis. Investigation and treatment strategies based on cost-effectiveness and scientific evidence are essential in the preparation of public health policies with the ultimate goal of reducing the incidence of fractures and, consequently, the direct and indirect costs associated with them. This article reviews the Brazilian burden of osteoporosis in terms of the prevalence and fractures attributable to the disease, the costs related to the investigation and management, as well as the impact of osteoporosis on the population as a whole and on affected individuals.

Low bone mineral density in young individuals is associated with greater gingival inflammation and recession

Most patients with osteoporosis are postmenopausal women or senile people who are deemed to have primary osteoporosis. However, young women, males, and atypical cases need further work up to evaluate the risk factors for secondary osteoporosis. A growing body of literature has accumulated regarding the role of osteoporosis in the onset and progression of periodontal disease and tooth loss. We hypothesized that secondary/idiopathic osteoporosis in young patients will be associated with worse periodontal status. Patients and controls who were seen in the general internal medicine outpatient clinic and who were less than 47 years of age were recruited between December 2005 and June 2011. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. Blood samples were obtained for bone turnover markers and secondary causes of low BMD. Periodontal variables were assessed. Forty-five women whose mean age was 33.9 ± 7.7 years were enrolled. The osteoporotic group consisted of 12 patients, the osteopenic group 17 patients, and the control group 16 subjects. Significantly higher gingival recession (GR), gingival bleeding time index, and hence gingival inflammation were noted in patients with secondary osteoporosis compared to healthy subjects. In logistic regression analysis, having osteoporosis was determined as the single risk factor for increased bleeding time (b = 0.871, p = 0.008), while having osteoporosis (b = 0.181, p = 0.001) and age (b = 0.010, p < 0.001) were significant parameters with regard to GR. In conclusion, low BMD in young individuals was associated with greater gingival inflammation and recession when compared to those individuals with normal BMD values.

Prevalence of causes of secondary osteoporosis and contribution to lower bone mineral density in HIV-infected patients

SUMMARY

Eighty-one percent of human immunodeficiency virus (HIV)-infected patients had one or more of seven evaluated causes of secondary osteoporosis, and this rate increases with age. The type and number of causes were associated with a lower bone mineral density (BMD), and with an increased rate of osteopenia/osteoporosis, regardless of age and body mass index.

INTRODUCTION

The objective of this study was to determine whether factors of secondary osteoporosis were associated with lower BMD in HIV.

METHODS

This was a cross-sectional study of 285 HIV-infected patients (25 % females) evaluating the impact of seven different factors of reduced BMD: hyperthyroidism, diabetes, chronic viral hepatitis, chronic kidney disease (CKD), hypovitaminosis D, secondary hyperparathyroidism, and hypogonadism. Dual-energy X-ray absorptiometry scan of the femoral neck was obtained at the clinical visit.

RESULTS

Mean age was 45.7 years; osteopenia and osteoporosis were diagnosed in 38 and 6 %, respectively. Overall, 230 patients (81 %) had secondary factors; 107 (38 %) had only 1 cause, 94 (33 %) had 2, and 28 (10 %) had 3 or more, predominantly vitamin D deficiency in 61 %, hepatitis C virus coinfection in 45 %, and secondary hyperparathyroidism in 27 %. The number of secondary factors was closely related to a lower BMD, which is statistically significant for patients having ≥2 causes (0.77 vs 0.73 g/cm(2), p = 0.02). The rate of osteopenia ranged from 36 % without any cause to 57 % with three or more, osteoporosis from 0 to 19 %, and Z-score <-2 SD from 0 to 27 %, respectively. In a multivariate linear regression, adjusting by age, body mass index, and HIV-related factors, the number of secondary factors was independently associated with a lower BMD (ß coefficient -0.134; p = 0.02), mainly due to patients with hepatitis C virus (HCV) coinfection, secondary hyperparathyroidism, and CKD.

CONCLUSIONS

A high prevalence of secondary causes of osteoporosis is observed in HIV-infected patients, and its type and cumulative number determine a lower BMD, after adjusting by age and body mass index.

Re-evaluating the role of vitamin D in the periodontium

The importance of vitamin D in maintaining skeletal health via the regulation of calcium has long been recognized as a critical function of this secosteroid. An abundance of literature shows an association between oral bone mineral density and some measure of systemic osteoporosis and suggests that osteoporosis/low bone mass may be a risk factor for periodontal disease. Recently, nonskeletal functions of vitamin D have gained notoriety for several reasons. Many cells that are not associated with calcium homeostasis have been demonstrated to possess membrane receptors for vitamin D. These include activated T and B lymphocytes, and skin, placenta, pancreas, prostate and colon cancer cells. In addition, vitamin D "insufficiency" is a worldwide epidemic and epidemiologic evidence has linked this condition to multiple chronic health problems, including cardiovascular and autoimmune diseases, hypertension and a variety of cancers. Interestingly, there is mounting evidence connecting diminished serum levels of vitamin D with increased gingival inflammation and supporting the concept of "continual vitamin D sufficiency" in maintaining periodontal health. The ability of vitamin D to regulate both the innate and the adaptive components of the host response may play an important role in this process. This review will examine the skeletal and nonskeletal functions of vitamin D, and explore its potential role in protecting the periodontium as well as in regulating periodontal wound healing.

Prevalence of subclinical contributors to low bone mineral density and/or fragility fracture

OBJECTIVE

The prevalence of subclinical contributors to low bone mineral density (BMD) and/or fragility fracture is debated. We evaluated the prevalence of subclinical contributors to low BMD and/or fragility fracture in the presence of normal 25-hydroxyvitamin D (25OHVitD) levels.

DESIGN

Prospective observational study.

METHODS

Among 1095 consecutive outpatients evaluated for low BMD and/or fragility fractures, 602 (563 females, age 65.4±10.0 years) with apparent primary osteoporosis were enrolled. A general chemistry profile, phosphate, 25OHVitD, cortisol after 1-mg overnight dexamethasone suppression test, antitissue transglutaminase and endomysial antibodies and testosterone (in males) were performed. Serum and urinary calcium and parathyroid hormone levels were also evaluated after 25OHVitD levels normalization. Vertebral deformities were assessed by radiograph.

RESULTS

In total, 70.8% of patients had low 25OHVitD levels. Additional subclinical contributors to low BMD and/or fragility fracture were diagnosed in 45% of patients, with idiopathic hypercalciuria (IH, 34.1%) and primary hyperparathyroidism (PHPT, 4.5%) being the most frequent contributors, apart from hypovitaminosis D. Furthermore, 33.2% of IH and 18.5% of PHPT patients were diagnosed only after 25OHVitD levels normalization. The subclinical contributors to low BMD and/or fragility fracture besides hypovitaminosis D were associated inversely with age (odds ratio (OR) 1.02, 95% CI 1-1.04, P=0.04) and BMI (OR 1.1, 95% CI 1.05-1.17, P=0.0001) and directly with fragility fractures (OR 1.89, 95% CI 1.31-2.73, P=0.001), regardless of BMD.

CONCLUSIONS

Subclinical contributors to low BMD and/or fragility fracture besides hypovitaminosis D are present in more than 40% of the subjects with apparent primary osteoporosis. Hypovitaminosis D masks a substantial proportion of IH and PHPT patients.

Role of TSH on Urinary Calcium Excretion In Post Menopausal Women of South Indian Population

BACKGROUND

Unforeseen aberrations in the hormonal status during the early postmenopausal period are responsible for several complications including osteoporosis. Thyroid Stimulating Hormone (TSH) receptors are isolated from various tissues including the bone. A low serum TSH level is known to stimulate osteoclastic activity in bone and accelerate bone resorption. Urinary calcium/creatinine (UCa/Cr) excretion ratio could be an indirect and an early indicator of loss of Bone Mineral Density (BMD). With this background, this study was planned to explore the association of serum TSH levels with the UCa/Cr excretion ratio.

METHODS

Forty eight women in the postmenopausal age group, with their menopausal age not more than seven years of duration were included in this study. Based on their TSH values, these subjects were divided into two groups A (TSH<0.5 mIU/L) and B (TSH>0.5mIU/L). Urinary calcium, UCa/Cr excretion ratio, serum phosphorous, calcium and calcium phosphorous multiplication products were estimated and compared between the two groups.

RESULTS

Twenty two (46%) women were biochemically asymptomatic hyperthyroid cases and Twenty six (54%) were euthyroid. This study documents high UCa/Cr in Group A compared to that of Group B (p<0.05). We also observed significant negative correlation of TSH with UCa/Cr excretion ratio (p=0.041, r = -0.43).

CONCLUSION

Low serum TSH levels were associated with increased UCa/Cr excretion ratio in postmenopausal women of South Indian population.

Idiopathic hypercalciuria and bone health

Calcium is an important participant in many physiologic processes including coagulation, cell membrane transfer, hormone release, neuromuscular activation, and myocardial contraction. The body cooperates in a sophisticated web of hormonally mediated interactions to maintain stable extracellular calcium levels. Calcium is vital for skeletal mineralization, and perturbations in extracellular calcium may be corrected at the expense of bone strength and integrity. The aim of this review is to delineate our current understanding of idiopathic hypercalciuria in the context of bone health, specifically its definition, etiology, epidemiology, laboratory evaluation, and potential therapeutic management.

Treatment of osteopenia

The majority of osteoporotic fractures happen in individuals with BMD t-scores in the osteopenic range (-2,5< t-score <-1). However, widespread use of anti-osteoporotic medication in this group based on t-score alone is not advisable because: 1) the number needed to treat is much higher (NNT>100) than in patients with fractured and t-score below -2,5 (NNT 10-20); 2)while specific osteoporosis treatments have demonstrated significant reductions of the fracture risk in patients with t-score <-2, 5, the efficacy in patients in the osteopenic range is less well established. Therefore, an osteopenic t-score does not in itself constitute a treatment imperative. Generally, osteopenia has to be associated with either low energy fracture(s) or very high risk for future fracture as assessed with risk calculators like FRAX to warrant specific osteoporosis therapy. Vertebral fractures are now conveniently assessed using lateral x-rays from DXA machines. In the vast majority of cases antiresorptive treatments (mainly hormone replacement therapy and SERMS in younger and bisphosphonates or Denosumab in older women) are the treatments of choice in this group of patients,-only rarely is anabolic therapy indicated.

Unrecognized and unappreciated secondary causes of osteoporosis

There are a substantial number of secondary causes of osteoporosis that can be identified through appropriate evaluation. Unrecognized celiac disease, Monoclonal gamopathy of undetermined significance (MGUS), impaired renal function, diabetes mellitus, and renal tubular acidosis are just a few of the more common secondary causes of osteoporosis. Through targeted laboratory tests, many secondary causes of osteoporosis can be identified.

The prevalence of recognized contributors to secondary osteoporosis in South East Asian men and post-menopausal women. Are Z score diagnostic thresholds useful predictors of their presence?

The prevalence of secondary contributors to osteoporosis in our population of SE Asian patients is high. Though various low thresholds Z score values have been proposed as suggestive of a high likelihood of secondary osteoporosis, they appear to have only limited discriminatory value in identifying a secondary cause.

INTRODUCTION

Many patients with osteoporosis have significant secondary contributors towards their bone loss. The sensitivity and diagnostic utility of using Z score thresholds to screen for secondary osteoporosis have not yet been convincingly demonstrated nor has there been any previous attempt to estimate the prevalence of secondary osteoporosis in South East Asia. We aimed to study the prevalence of commonly recognized contributors and to determine the discriminatory ability of Z score thresholds in screening for them in Singaporean men and post-menopausal women with osteoporosis.

METHOD

Three hundred thirty-two consecutive patients seen at the osteoporosis clinic of the largest hospital in Singapore were evaluated. The frequencies of the different contributors were determined and sensitivities, specificities, and positive and negative predictive values (PPV and NPV) of pre-specified Z score cut-off values calculated.

RESULTS

Vitamin D deficiency was present in 18.5% of the patients, hyperthyroidism in 10.11%, primary hyperparathyroidism in 1%, secondary hyperparathyroidism in 6%, hypercalciuria in 21.63%, glucocorticoid use in 8.43%, and hypogonadism in 9.4% of males. A Z score value of <-1 had a sensitivity of 71.7 % and NPV of 66.2 % in identifying the presence of a secondary contributor in post-menopausal women. The sensitivity and NPV of a similar threshold in men was 59.1 and 40 %, respectively. ROC curves used to investigate various Z score diagnostic thresholds for sensitivity and specificity showed that they provided poor predictive value for the presence of secondary osteoporosis.

CONCLUSION

Secondary contributors are common in our patients with osteoporosis. Z score diagnostic thresholds have only limited value in discriminating between primary and secondary osteoporosis.

Secondary fracture prevention

Osteoporosis causes no symptoms until there is a fracture. Although screening for osteoporosis is recommended for some populations, patients may present with a fragility fracture. Such patients are at high risk for subsequent fractures. Despite this high risk and the presence of generally safe and effective osteoporosis therapy, only a minority of low trauma fracture patients have evaluation and treatment of underlying osteoporosis. A brief summary of the evaluation and medical treatment of the post-fracture patient is provided. Several institutions, integrated health systems, and countries have instituted programs to identify, evaluate, and treat fragility fracture patients. Such programs have had variable success. This article describes some of the programs that work, their cost-effectiveness, and the applicability to the generally non-integrated US health care system. It is clear that better management of the post-fracture patient (and other high-risk patients) will lead to fewer fractures, decreased morbidity and mortality, and long-term cost savings.

Prevalência de hipercalciúria em mulheres na pós-menopausa com osteoporose

OBJETIVO: Analisar a prevalência de hipercalciúria em mulheres na pós-menopausa com osteoporose e avaliar associação de hipercalciúria com parâmetros clínicos e do metabolismo osteomineral. SUJEITOS E MÉTODOS: Foram estudadas 127 mulheres. A calciúria foi determinada em urina de 24 horas. A DMO foi medida em coluna lombar e fêmur por dupla emissão de energia (DXA). RESULTADOS: A média de idade foi de 64 ± 8 anos. De acordo com a excreção urinária de cálcio, as pacientes foram divididas em normo e hipercalciúricas (HC). Das 127 pacientes, 19 (15%) foram classificadas como HC. Houve diferença entre os grupos apenas na idade de início da menopausa (46 ± 6 vs. 50 ± 3 anos HC, p < 0,0005). Não houve associação entre calciúria e idade, IMC, DMO, cálcio, fósforo, PTH e fosfatase alcalina. CONCLUSÃO: A HC é frequente em mulheres na pós-menopausa com osteoporose, e a medida da calciúria deve ser incluída na investigação dessas pacientes.

Osteoporosis, frailty and fracture: implications for case finding and therapy

In almost all patients with incident fractures, the absolute risk of subsequent fracture and mortality is highest immediately after the fracture is incurred; the risk is substantially increased in frail elderly patients. The risk factors for incident fractures, such as bone fragility, tendency to fall and the presence of metabolic bone disease, remain underdiagnosed and undertreated. Here, we review the evidence that demonstrates the influence of these risk factors on susceptibility to subsequent fracture and mortality after an incident fracture, and discuss the tools available to predict these outcomes. In this Review, we also propose a systematic, coordinator-based approach to assessment of risk, allocation of treatment and follow-up in all patients over 50 years of age who present with a fracture. The aim of this proposed multistep procedure is to improve the prevention of secondary fracture, decrease mortality rates and reduce patient undertreatment or overtreatment.

Appraising osteoporosis care gaps

To evaluate physician response to dual-energy X-ray absorptiometry (DXA) report within the Geisinger Medical Center's Mobile DXA Program and treatment adherence at 1 year. Between 10/01/2004 and 3/30/2005, 1381 DXA scans were performed in our Mobile DXA Program. Within this cohort, we identified 366 high-risk, drug-naive patients and report the percentage of patients placed on prescription drug therapy within 90 days of DXA result. Additionally, we identified 191 patients with Z-score of -1.0 or worse and report whether laboratory tests were ordered within 90 days of DXA results in this group. Finally, we determined treatment adherence at 1 year. 269 patients (74%) were offered prescription therapy within 3 months of DXA results. Of those, 210 (57%) were still adherent to drug therapy at 1 year. The main reason for discontinuation of treatment was an adverse drug side effect. Additionally, in 50% cases, physicians ordered 1 or more laboratory tests to evaluate low Z-score. Within our Mobile DXA Program, 74% of high-risk, drug-naïve patients were treated. Interestingly, in 50% cases, when a low Z-score was reported, our physicians ordered 1 or more laboratory tests. Treatment adherence was 57% at 1 year.

[2011 Up-date of the consensus statement of the Spanish Society of Rheumatology on osteoporosis]

OBJECTIVE

Due to increasing improvement in the diagnosis, evaluation and management of osteoporosis and the development of new tools and drugs, the Spanish Society of Rheumatology (SER) has promoted the development of recommendations based on the best evidence available. These recommendations should be a reference to rheumatologists and other health professionals involved in the treatment of patients with osteoporosis.

METHODS

Recommendations were developed following a nominal group methodology and based on a systematic review. The level of evidence and degree of recommendation were classified according to the model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through Delphi technique. Evidence from previous consensus and available clinical guidelines was used.

RESULTS

We have produced recommendations on diagnosis, evaluation and management of osteoporosis. These recommendations include the glucocorticoid-induced osteoporosis, premenopausal and male osteoporosis.

CONCLUSIONS

We present the SER recommendations related to the biologic therapy risk management.

Choosing a treatment for patients at the time a fracture is presented

The occurrence of a fragility fracture is an opportunity to recognize osteoporosis and begin treatment to reduce the risk of another fracture. However, selecting the treatment may have an impact on the incident fracture and this requires careful consideration of the patient and the treatment choices. There is no consensus regarding the management of osteoporosis at the time of an incident fracture. This review will consider the treatment options after a fragility fracture.

Short-term and long-term orthopaedic issues in patients with fragility fractures

BACKGROUND

Patients with impaired bone quality who suffer a fragility fracture face substantial challenges in both their short- and long-term care. In addition to poor bone quality, many of these patients have multiple medical comorbidities that alter their surgical risk and affect their ultimate functional recovery. Some medical issues can contribute to the altered bone quality and must be addressed to prevent future fractures.

QUESTIONS/PURPOSES

This review summarizes the modifications in perioperative management and fracture fixation in patients with common fragility fractures who have impaired bone quality. It also summarizes the postoperative diagnosis and treatment of secondary causes of impaired bone quality in these patients.

METHODS

We performed a PubMed search, and literature published after 2000 was prioritized, with the exception of benchmark clinical trial studies published before 2000.

RESULTS

Patients with altered bone quality require rapid perioperative management of multiple medical comorbidities. Implant selection in patients with poor quality bone should permit early weightbearing, and constructs should maximize surface area contact with the remaining bone. Long-term diagnosis and treatment of other disease states contributing to poor bone quality (vitamin D deficiency/insufficiency, hypothyroidism, hyperthyroidism, hyperparathyroidism, Cushing's disease, and hypogonadism) must occur to minimize the chances of future fractures.

CONCLUSIONS

Recognition of patients with impaired bone quality and proper treatment of their special needs in both the short and long term are essential for their best opportunity for maximal functional recovery and prevention of future fractures.

Implementation of osteoporosis guidelines: a survey of five large fracture liaison services in the Netherlands

SUMMARY

Implementation of case findings according to guidelines for osteoporosis in fracture patients presenting at a Fracture Liaison Service (FLS) was evaluated. Despite one guideline, all FLSs differed in the performance of patient selection and prevalence of clinical risk factors (CRFs) indicating the need for more concrete and standardised guidelines.

INTRODUCTION

The aim of the study was to evaluate the implementation of case findings according to guidelines for osteoporosis in fracture patients presenting at FLSs in the Netherlands.

METHODS

Five FLSs were contacted to participate in this prospective study. Patients older than 50 years with a recent clinical fracture who were able and were willing to participate in fracture risk evaluation were included. Performance was evaluated by criteria for patient recruitment, patient characteristics, nurse time, evaluated clinical risk factors (CRFs), bone mineral density (BMD) and laboratory testing and results of CRFs and BMD are presented. Differences between FLSs were analysed for performance (by chi-square and Student's t test) and for prevalence of CRFs (by relative risks (RR)).

RESULTS

All FLSs had a dedicated nurse spending 0.9 to 1.7 h per patient. During 39 to 58 months follow-up, 7,199 patients were evaluated (15 to 47 patients/centre/month; mean age, 67 years; 77% women). Major differences were found between FLSs in the performance of patient recruitment, evaluation of CRFs, BMD and laboratory testing, varying between 0% and 100%. The prevalence of CRFs and osteoporosis varied significantly between FLSs (RR between 1.7 and 37.0, depending on the risk factor).

CONCLUSION

All five participating FLSs with a dedicated fracture nurse differed in the performance of patient selection, CRFs and in the prevalence of CRFs, indicating the need for more concrete and standardised guidelines to organise evaluation of patients at the time of fracture in daily practice.

Secondary osteoporosis in men and women: clinical challenge of an unresolved issue

OBJECTIVE

To evaluate the clinical and etiological factors of osteoporosis. We also tested the FRAX algorithm to compare the assessment of fracture risk in patients with primary or secondary osteoporosis.

METHODS

A prospective study carried out in a large sample of 123 men and 246 women. All subjects had a biochemical, densitometric, and radiological examination of thoracic and lumbar spine.

RESULTS

The prevalence of primary (men 52.9% vs women 50%; p = nonsignificant) and secondary (men 21.1% vs women 17.5%; p = nonsignificant) osteoporosis did not differ between the sexes. In contrast, the prevalence of primary osteoporosis was significantly higher than secondary causes (p < 0.0001) in both men and women. While women came to our attention for prevention of osteoporosis, men sought help because of clinical symptoms or disease-related complications, such as fractures. As evaluated by the FRAX tool, patients with osteopenia do not need treatment, in agreement with Italian guidelines. The estimated risk of major osteoporotic and hip fractures was significantly higher in women with secondary osteoporosis compared to men and also compared to women with primary osteoporosis.

CONCLUSION

The prevalence of secondary osteoporosis in men is similar to that in women and it is less frequent than commonly reported. In patients with secondary osteoporosis, FRAX calculation may provide an estimate of a particularly high fracture risk in patients whose bone fragility is usually attributed to another disease.

Osteoporosis in men: the value of laboratory testing

Evaluation of 234 men referred for osteoporosis found many with undiagnosed secondary causes and multiple unrecognized risk factors.

INTRODUCTION

Studies in women with postmenopausal osteoporosis suggest that many have unrecognized disorders affecting bone. Men are considered more likely to have underlying, possibly correctable causes. We studied the prevalence of risk factors, secondary causes, and laboratory abnormalities in men with and without previously known causes for osteoporosis.

METHODS

We reviewed the charts of 234 men with osteoporosis diagnosed by bone mineral density testing. In addition to screening chemistries, 25-hydroxyvitamin D, testosterone, luteinizing hormone, follicle-stimulating hormone, thyroid-stimulating hormone, and spot urinary calcium-to-creatinine ratio were measured.

RESULTS

The mean age was 70.6 years and mean weight was 76.4 kg. The mean T-score for spine, femoral neck, and forearm was -2.2, -2.4, and -2.3, respectively. Evaluation revealed secondary osteoporosis in 75% overall including hypogonadism, vitamin D deficiency, hypercalciuria, subclinical hyperthyroidism, and hyperparathyroidism. In those men with known secondary osteoporosis at the time of dual energy X-ray absorptiometry testing, additional diagnoses were found in just over half. Vitamin D deficiency and insufficiency were very common, and other common risk factors for osteoporosis included age >65, current smoking, and prior fracture. Half of the subjects had ≥ 4 risk factors.

CONCLUSION

Evaluation revealed a specific cause in about half of men thought to have primary osteoporosis. Among men with known secondary osteoporosis, additional risk factors and secondary causes were frequently identified. In conclusion, a relatively modest evaluation of men with osteoporosis will often provide useful information.

[Increase of PTH in post-menopausal osteoporosis]

AIMS

Increased parathyroid values (PTH) serum values can be observed in postmenopausal women. However, the clinical repercussion and causes of this finding are poorly understood. This study has aimed to analyze the prevalence and conditions associated to the increased serum PTH levels in postmenopausal women with osteoporosis as well as their clinical characteristics.

METHODS

Post-menopausal women with osteoporosis were included in the study. PTH, 25-hydroxyvitamin D (25OHD), 24-h urinary calcium, glomerular filtration rate (GFR) and calcium intake were evaluated. The prevalence of increased PTH serum values and its relationship with vitamin D deficiency and insufficiency, kidney failure, hypercalciuria and calcium intake deficiency were evaluated, these being conditions that may increase PTH secretion.

RESULTS

A total of 204 postmenopausal women with osteoporosis with a mean age of 64 years were included. Increase PTH levels (>65 pg/ml) were observed in 35% and 5 women had primary hyperparathyroidism. Women with increased serum PTH levels were older (67 ± 9 years) were old than those with normal PTH levels (63 ± 11 years) (P=0.03). PTH elevation was associated to calcium intake deficiency (<800 mg/d) in 81% of the women, to a vitamin D deficiency and insufficiency in 55% and 86%, respectively, renal insufficiency in 35% and hypercalciuria in 17% of the patients. These values, however, did not differ when compared with patients with normal PTH serum levels. Serum PTH levels were related to age (r=0.19, P=0.01) but not to 25OHD or GFR values.

CONCLUSIONS

One third of the post-menopausal women with osteoporosis had elevated PTH levels. This was due to primary hyperparathyroidism in 10%. The prevalence of conditions associated to the increase in PTH (reduced calcium intake, 25-hydroxyvitamin D, renal failure and hypercalciuria) is similar to that observed in women with normal PTH values.

The utility of BMD Z-score diagnostic thresholds for secondary causes of osteoporosis

This very large dual X-ray absorptiometry (DXA) cohort confirmed a significant, inverse relationship between bone mineral density (BMD) Z-scores and the presence of secondary causes of osteoporosis but receiver operating characteristic (ROC) curves indicate that Z-score diagnostic thresholds (such as -2.0) discriminate poorly between the presence and absence of secondary causes of osteoporosis.

INTRODUCTION

BMD Z-score diagnostic thresholds have been proposed to detect secondary causes of osteoporosis. To determine the sensitivity and diagnostic utility of such thresholds, we analyzed comprehensive BMD and personal health information data from a large, multispecialty group practice.

METHODS

Adult subjects were assigned their lowest axial BMD Z-score and ICD-9 diagnosis codes for secondary causes of osteoporosis when cited at least twice in their electronic medical record. Multiple logistic regression was used to model the prevalence of matching ICD-9 codes as a function of Z-score. ROC curves were used to investigate various Z-score cut points for sensitivity and specificity.

RESULTS

Eighteen thousand six hundred seventy-four subjects were analyzed. Secondary causes of osteoporosis were identified in 31% of men and 16% of women. The frequency of secondary causes varied with age and between genders and varied inversely with Z-score. No inflection point was observed in this relationship to suggest a useful clinical decision threshold. The difference in mean Z-score of those with and without a secondary cause of osteoporosis was biologically slight (±0.3). Low Z-score diagnostic thresholds were insensitive to the presence of secondary causes of osteoporosis and provided relatively poor predictive value.

CONCLUSIONS

This DXA cohort confirmed a significant inverse relationship between Z-score and the presence of secondary causes of osteoporosis but diagnostic Z-score thresholds discriminate poorly between the presence and absence of secondary causes of osteoporosis. If only patients with very low Z-scores are evaluated for secondary causes of osteoporosis the diagnostic specificity may be high but most cases will be missed.

Cancer therapy associated bone loss: implications for hip fractures in mid-life women with breast cancer

PURPOSE

Aromatase inhibitors (AIs) have been recently associated with hip fractures. We present a case series of breast cancer survivors and a systematic review of bone health care in breast cancer.

EXPERIMENTAL DESIGN

We completed clinical assessments and bone density testing (BMD) of hip fractures from January 2005 to December 2008. Prefracture and 12-month functional status was obtained. Systematic review included case reports and review of MEDLINE, PubMed, EMBASE, and Food and Drug Administration Adverse Event Reporting System (FDA AERS) from January 1998 to December 2008 (search terms: breast cancer, bone loss, osteopenia, osteoporosis, malignancy, cancer treatment, menopause, adriamycin, cytoxan, tamoxifen, and AIs).

RESULTS

Median age was 53.5 years; five women had osteopenia, one osteoporosis. Five cases were ER (+), and received surgery, XRT chemotherapy, and anastrozole. Functional decline was noted at 12 months, with difficulty in performing heavy housekeeping, climbing stairs, and shopping. The FDA AERS database included 228 cases of fractures associated with breast cancer therapy; 77/228 (29.4%) were hip or femur fractures. Among mid-life women under the age of 64 years there were 78 fractures; 15/228 (19%) were hip and femur fractures. AIs were the most common drug class associated with fractures (n = 149, 65%).

CONCLUSIONS

Cancer treatment induced bone loss results in hip fractures among mid-life women with breast cancer. Hip fractures occur at younger ages and higher BMD than expected for patients in this age group without breast cancer. Hip fractures result in considerable functional decline. Greater awareness of this adverse drug effect is needed.

Bone disease in HIV infection: a practical review and recommendations for HIV care providers

Low bone mineral density (BMD) is prevalent in human immunodeficiency virus (HIV)-infected subjects. Initiation of antiretroviral therapy is associated with a 2%-6% decrease in BMD over the first 2 years, a decrease that is similar in magnitude to that sustained during the first 2 years of menopause. Recent studies have also described increased fracture rates in the HIV-infected population. The causes of low BMD in individuals with HIV infection appear to be multifactorial and likely represent a complex interaction between HIV infection, traditional osteoporosis risk factors, and antiretroviral-related factors. In this review, we make the point that HIV infection should be considered as a risk factor for bone disease. We recommend screening patients with fragility fractures, all HIV-infected post-menopausal women, and all HIV-infected men ⩾50 years of age. We also discuss the importance of considering secondary causes of osteoporosis. Finally, we discuss treatment of the more severe cases of bone disease, while outlining the caveats and gaps in our knowledge.

Osteoporosis update from the 2010 santa fe bone symposium

The 11th Santa Fe Bone Symposium was held in Santa Fe, NM, USA, on August 6-7, 2010. This annual event addresses clinically relevant advances in the fields of osteoporosis and metabolic bone disease. The venue includes plenary presentations by internationally recognized experts, oral presentations of abstracts, and interactive panel discussions of challenging cases and controversial issues. Attendees are active participants throughout the symposium program. Topics for the 2010 symposium included potential applications of novel technologies for the assessment of skeletal health for research and clinical practice; new and emerging treatments for osteoporosis; appropriate use of pharmacological agents to prevent osteoporosis; controversies with bisphosphonate therapy; practical applications of the World Health Organization fracture risk assessment tool (FRAX; World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK); insights into the use of osteoanabolic agents to enhance fracture healing; and challenges in laboratory testing in the assessment of factors contributing to skeletal fragility. Concurrent sessions focused on critical thinking for technologists in the acquisition and analysis of data with dual-energy X-ray absorptiometry. The key messages from each presentation, including the best available medical evidence and potential current and future clinical applications, are provided here.

Management of skeletal health in patients with asymptomatic primary hyperparathyroidism

Asymptomatic primary hyperparathyroidism (PHPT) may cause adverse skeletal effects that include high bone remodeling, reduced bone mineral density (BMD), and increased fracture risk. Parathyroid surgery, the definitive treatment for PHPT, has been shown to increase BMD and appears to reduce fracture risk. Current guidelines recommend parathyroid surgery for patients with symptomatic PHPT or asymptomatic PHPT with serum calcium >1mg/dL above the upper limit of normal, calculated creatinine clearance <60 mL/min, osteoporosis, previous fracture, or age <50 yr. The type of operation performed (parathyroid exploration or minimally invasive procedure) and localizing studies to identify the abnormal parathyroid glands preoperatively should be individualized according to the skills of the surgeon and the resources of the institution. In patients who choose not to be treated surgically or who have contraindications for surgery, medical therapy should include a daily calcium intake of at least 1200 mg and maintenance of serum 25-hydroxyvitamin D levels of at least 20 ng/mL (50 nmol/L). Bisphosphonates and estrogens have been shown to provide skeletal benefits that appear to be similar to parathyroid surgery. Cinacalcet reduces serum calcium in PHPT patients with intractable hypercalcemia but has not been shown to improve BMD. It is not known whether any medical intervention reduces fracture risk in patients with PHPT. There are insufficient data on the natural history and treatment of normocalcemic PHPT to make recommendations for management of this disorder.

Strategies for treatment to prevent fragility fractures in postmenopausal women

The objective of treatment of osteoporosis is to decrease the risk of fractures in patients at high risk for a first or subsequent fracture. The efficacy of treatment will depend on the efficiency and level of implementation of clinical case finding to select patients at risk, the results of additional investigations, the efficacy, tolerance and safety of medical intervention and the adherence to treatment during follow-up. Each of these steps is critical in treatment in daily practice. Failure to consider one or another step can result in suboptimal fracture prevention or overtreatment. The aim of case finding is to identify patients for treatment, who have disease characteristics of patients in whom fracture prevention has been demonstrated in randomised controlled trials (RCTs). These include patients with a low-trauma hip or vertebral fracture, with a low bone mineral density (BMD) or with a high risk of fracture based on the presence of clinical risk factors (CRFs) for osteoporosis and fractures such as included in the FRAX case-finding algorithm, with or without BMD. Case finding starts clinically, with systematic or opportunistic doctor- and/or patient-driven evaluation for the presence of CRFs, but its implementation is low. Further investigations aim to assess the risk of fracture(s) and to have baseline measurements for the subsequent monitoring of treatment, to exclude diseases that mimic osteoporosis, to identify the cause of osteoporosis and contributory factors and to select the most appropriate treatment. Medical intervention consists of providing information about osteoporosis to the patient, lifestyle advice, optimalisation of calcium intake and vitamin D status, fall prevention to reduce fall risk, correction of reversible contributors to secondary osteoporosis and a wide array of drugs for prevention of a first or subsequent vertebral, hip and non-vertebral, non-hip fracture. Drug treatment is based on manipulation of bone remodelling by inhibiting bone resorption (bisphosphonates, selective oestrogen-receptor modulator (SERMs), calcitonin), stimulating bone formation (parathyroid hormone) or mixed effects (strontium ranelate). Follow-up allows to check tolerance and safety, to optimise adherence and to decide about adequacy of response, duration and switching of therapy.

Progress in osteoporosis and fracture prevention: focus on postmenopausal women

In the past decade, we have witnessed a revolution in osteoporosis diagnosis and therapeutics. This includes enhanced understanding of basic bone biology, recognizing the severe consequences of fractures in terms of morbidity and short-term re-fracture and mortality risk and case finding based on clinical risks, bone mineral density, new imaging approaches, and contributors to secondary osteoporosis. Medical interventions that reduce fracture risk include sufficient calcium and vitamin D together with a wide spectrum of drug therapies (with antiresorptive, anabolic, or mixed effects). Emerging therapeutic options that target molecules of bone metabolism indicate that the next decade should offer even greater promise for further improving our diagnostic and treatment approaches.

Clinical assessment of fracture risk and novel therapeutic strategies to combat osteoporosis

OBJECTIVE

To review the latest tools in the clinical assessment of fracture risk and to review new and emerging options for osteoporosis therapy.

DESIGN

Retrospective analysis of published studies regarding the diagnosis and treatment of osteoporosis.

RESULT(S)

Large-scale epidemiologic data were recently assembled by the World Health Organization to produce a Web-based clinical assessment tool, FRAX, which uses clinical and historical data to provide prompt assessment and quantitation of fracture risk. The FRAX models were developed from studying population-based cohorts in Europe, North America, Asia, and Australia. The FRAX algorithms indicate the 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (at the clinical spine, forearm, hip, or shoulder) on which to base treatment decisions. Recent progress in the study of bone metabolism including anabolic pathways that enhance bone maintenance, is anticipated to improve the ways in which skeletal health can be maintained and osteoporosis can be treated.

CONCLUSION(S)

Using FRAX, fracture risk in now easily assessed in the clinical setting. New and emerging treatment strategies for bone maintenance are reviewed. Improved assessment of fracture risk, combined with tailored therapies for at-risk patients, will increase the number of patients who receive appropriate bone-sparing therapies.

Evaluation of secondary causes of bone loss in a primary care setting

OBJECTIVE

To evaluate the clinical and laboratory work-up for secondary causes of bone loss in a primary care setting.

METHODS

We conducted a retrospective review of medical records of 100 patients with either osteoporosis or osteopenia, who presented to a university-based primary care clinic. Patients with chronic kidney disease or a history of organ transplantation were excluded, as were premenopausal women.

RESULTS

Age at menopause was ascertained in 43% of female patients. Only 2% of patients were asked specifically about symptoms of malabsorption, whereas a history of malignant disease or its treatment was elicited from 24%. Of the overall study group, 50% were asked about a history of thyroid disease and 18% about a history of liver disease. Testicular examination was documented in 40% of male patients. Serum calcium and creatinine, complete blood cell count, and thyroid function tests were evaluated in 100% of patients. Vitamin D status was assessed in only 1 patient; no study patient had a 24-hour urine collection for determination of calcium excretion. Serum parathyroid hormone was measured in 7% and serum phosphorus in 10% of patients. Sixty percent of male patients had their testosterone levels assessed. Although the serum creatinine level was determined in all patients, only 1% had a formal estimation of the creatinine clearance or glomerular filtration rate.

CONCLUSION

The evaluation of secondary causes of bone loss was notably inadequate in our study population. Because most patients with osteoporosis or osteopenia are managed in the primary care setting, a distinct need exists for consensus guidelines and recommendations from professional endocrine organizations to advise primary care physicians in the appropriate diagnostic evaluation for secondary causes of bone loss in such patients.

Osteomalacia

The finding of low bone mineral density with a T-score of -2.5 or below on dual energy x-ray absorptiometry is usually reported as indicating that the patient has "osteoporosis" according to the World Health Organization classification, and, in postmenopausal women, it is often assumed that this is due to estrogen deficiency. However, up to one third of postmenopausal women have a secondary cause of low density, including osteomalacia. Osteomalacia is defined as a mineralization defect caused by disorders that lead to decreased mineralization of bone. Clues from the history, physical examination, laboratory tests, and radiographs may indicate that the patient suffers from a form of osteomalacia rather than postmenopausal estrogen deficiency alone. Establishing a diagnosis of osteomalacia when present is critical to proper management of the patient.

Prevalence of Secondary Causes of Bone Loss Among Breast Cancer Patients With Osteopenia and Osteoporosis

Purpose

To determine the prevalence of secondary causes of bone loss among patients with breast cancer with osteopenia and osteoporosis.

Patients and Methods

All women referred to a bone health clinic over a 6-year period for bone evaluation were included in this retrospective study and stratified based on presence or absence of a breast cancer history. The prevalence of secondary causes of bone loss in the two groups was compared.

Results

Of the 238 women identified, 64 women had breast cancer. The non–breast cancer group (n = 174) was significantly older (P = .015), had a lower mean weight (P = .019), lower 25 hydroxy-vitamin D level (P = .019), and greater degree of bone loss in both the spine and hip (P < .001 and 0.004, respectively). The presence of at least one secondary cause of bone loss, excluding cancer-related therapies, was seen in 78% of the breast cancer patient group and in 77% of the non–breast cancer group (P = not significant). Newly diagnosed metabolic bone disorders were seen in 58% of the breast cancer population. The most common was vitamin D deficiency, seen in 38% of patients in the breast cancer group and 51% of patients in the non–breast cancer group. Idiopathic hypercalciuria was diagnosed in 15.6%, primary hyperparathyroidism in 1.6%, and normocalcemic hyperparathyroidism in 3.1% of the breast cancer population.

Conclusion

A high prevalence of secondary causes of bone loss among patients with breast cancer supports a comprehensive evaluation in these patients, particularly those considering therapy with an aromatase inhibitor.

Clinical challenges in the management of osteoporosis

While knowledge regarding the diagnosis and treatment of osteoporosis has expanded dramatically over the last few years, gaps in knowledge still exist with guidance lacking on the appropriate management of several common clinical scenarios. This article uses fictional clinical scenarios to help answer three challenging questions commonly encountered in clinical practice. The first clinical challenge is when to initiate drug therapy in a patient with low bone density. It is estimated that 34 million America have low bone density and are at a higher risk for low trauma fractures. Limitations of using bone mineral density alone for drug therapy decisions, absolute risk assessment and evidence for the cost-effectiveness of therapy in this population are presented. The second clinical challenge is the prevention and treatment of vitamin D deficiency. Appropriate definitions for vitamin D insufficiency and deficiency, the populations at risk for low vitamin, potential consequences of low vitamin D, and how to manage a patient with low vitamin D are reviewed. The third clinical challenge is how to manage a patient receiving drug therapy for osteoporosis who has been deemed a potential treatment failure. How to define treatment failure, common causes of treatment failure, and the approach to the management of a patient who is not responding to appropriate osteoporosis therapy are discussed.

Osteoporosis primer for the vertebroplasty practitioner: expanding the focus beyond needles and cement

Osteoporosis is a common cause of vertebral compression fractures. Although vertebroplasty is used to treat the pain, the risk of additional compression fractures is very high in these patients. Adequate evaluation and management of the underlying osteoporosis is critical to reducing the risk of subsequent fractures. Such an evaluation involves understanding the underlying physiology of osteoporosis and the role of calcium, vitamin D, prescription medication, and lifestyle changes. This brief review is intended to familiarize neuroradiologists with these aspects so they can advise patients about optimizing fracture risk reduction.