AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS- 2020 UPDATE EXECUTIVE SUMMARY

Novel formulations of oral bisphosphonates in the treatment of osteoporosis

Oral bisphosphonates are a key intervention in the treatment of osteoporosis and in reducing the risk of fragility fractures. Their use is supported by over 3 decades of evidence; however, patient adherence to oral bisphosphonates remains poor in part due to complex dosing instructions and adverse events, including upper gastrointestinal symptoms. This problem has led to the development of novel oral bisphosphonate formulations. Buffered, effervescent alendronate is dissolved in water and so seeks to reduce upper gastro-intestinal adverse events, and gastro-resistant risedronate aims to reduce the complexity of dosing procedure (e.g. fasting prior to consumption) whilst still maintaining the efficacy of fracture risk reduction. Clinical trials and real-world data have been employed to demonstrate some benefits in terms of reduced upper gastro-intestinal adverse events, adherence, persistence and health economic outcomes. This report describes the result of an ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis) expert working group, which explores where oral bisphosphonates sit in current clinical practice guidelines, review their risk-benefit profile and the consequences of poor adherence before exploring novel oral bisphosphonate formulations and their potential clinical and health economic impact. Further research is required but there are signs that these novel, oral bisphosphonate formulations may lead to improved tolerance of oral bisphosphonates and thus, improved adherence and fracture outcomes.

Current situation of shared decision making in osteoporosis: A comprehensive literature review of patient decision aids and decision drivers

Background and Aims

Osteoporosis is a systemic skeletal disease characterized by low bone mass and microstructural deterioration of bone tissues, resulting in bone fragility and increased fracture risk. It is the most common bone-related disease in the population. However, the proportion of patients who start treatment but discontinue it during the first year is very high (around 50%). Endeavors are made to promote patient participation in treatment by implementing patient decision aids (PDA), whose function is to help the patient make disease-related decisions. We aim to summarize the characteristics of the currently available PDA for osteoporosis, as well as deciding factors.

Methods

Comprehensive review of the literature.

Results

Currently, eleven PDAs can be found for osteoporosis. These PDA have different characteristics or options such as information about treatments tailored to patient needs, graphic information of the results (to facilitate understanding), personal histories (learning), tests to check the knowledge acquired, provision of evidence, clinical practice guidelines or a final summary to share with their doctor. Only five of these PDAs can be considered complete since they provide relevant disease information and therapeutic options to the patient, promote patient's reflection and foment patient-physician discussion.

Conclusions

This study provides an update on the current state of decision making on osteoporosis and available PDA, which can help engage the patient through shared decision-making by considering, among other things, patient preferences. Physicians should consider PDA, as it may promote adherence and effectiveness of treatment.

Prevalent vertebral fractures among urban-dwelling Chinese postmenopausal women: a population-based, randomized-sampling, cross-sectional study

In this population-based, cross-sectional study, we investigated vertebral fracture (VF) prevalence among Chinese postmenopausal women. We found 14.7% of population had VFs, which increased with age. Age ≥ 65 years, hip fracture, and densitometric osteoporosis were significantly associated with VFs. The prevalence of osteoporosis was remarkably high.

PURPOSE

To investigate VF prevalence among Chinese postmenopausal women in this population-based, randomized-sampling, cross-sectional study.

METHODS

The investigator obtained lists of women from communities. Randomization was performed using SAS programming based on age group in each region. Postmenopausal women aged ≥ 50 years in the urban community were included. The investigator interviewed subjects to collect self-reported data and measured BMD. Spine radiographs were adjudicated by Genant's semi-quantitative method. VFs were defined as fractures of at least one vertebra classified by Genant's score 1-3 and were analyzed using descriptive statistics.

RESULTS

A total of 31,205 women listed for randomized sampling from 10 Tier-3 hospitals at 5 regions. Of 2634 women in the full analysis set, 14.7% (388/2634, 95% CI: 13.4, 17.1) had prevalent VFs. VF prevalence increased with age (Cochran-Armitage test p < 0.0001) and was significantly higher in women aged ≥ 65. VF prevalence did not differ between North (14.4%, 95% CI: 12.5, 16.4) and South China (15.1%, 95% CI: 13.3, 17.1). In women with no prior VFs, prevalent VFs were 12.4% (95% CI: 11.2, 13.7). Age ≥ 65 years (OR: 2.57, 95% CI: 1.91, 3.48), hip fracture (OR: 2.28, 95% CI: 1.09, 4.76), and densitometric osteoporosis (OR: 2.52, 95% CI: 1.96, 3.22) were significantly associated with prevalent VFs. Prevalence of osteoporosis was 32.9% measured by BMD and 40.8% using NOF/IOF clinical diagnosis criteria.

CONCLUSION

VFs are prevalent among Chinese postmenopausal women who were ≥ 50 years and community-dwelled. Osteoporosis prevalence is remarkable when fragile fractures were part of clinical diagnosis.

Remote Management of Osteoporosis

Purpose of Review

Osteoporosis management has evolved significantly over the past decade, with telehealth emerging as an effective tool to manage bone health in a growing patient population. This review explores the advantages and disadvantages of telehealth use for osteoporosis management while highlighting recent studies of clinical importance.

Recent Findings

A wide variety of telehealth approaches are used today, from phone or video telemedicine appointments with physicians and advanced practice providers, to electronic systems for triage and consultation with osteoporosis specialists. Contemporary studies show that telehealth can facilitate health care access to underserved communities and enhance physician-patient communication, as well as provide patient education. However, barriers such as inexperience or lack of access to technology, suboptimal patient-clinician relationship building process, and difficulties with follow-up have limited the use of telehealth to certain situations.

Summary

Telehealth has proven to be an effective resource for managing and treating osteoporosis patients. As its use continues to grow, important limitations must be accounted for to avoid lapses in care. Further research should keep these factors in mind as the use of this technology progresses.

Osteoporosis Diagnostic Model Using a Multichannel Convolutional Neural Network Based on Quantitative Ultrasound Radiofrequency Signal

Quantitative ultrasound (QUS) is a promising screening method for osteoporosis. In this study, a new method to improve the diagnostic accuracy of QUS was established in which a multichannel convolutional neural network (MCNN) processes the raw radiofrequency (RF) signal of QUS. The improvement in the diagnostic accuracy of osteoporosis using this new method was evaluated by comparison with the conventional speed of sound (SOS) method. Dual-energy X-ray absorptiometry was used as the diagnostic standard. After being trained, validated and tested in a data set consisting of 274 participants, the MCNN model could significantly raise the accuracy of osteoporosis diagnosis compared with the SOS method. The adjusted MCNN model performed even better when adjusted by age, height and weight data. The sensitivity, specificity and accuracy of the adjusted MCNN method for osteoporosis diagnosis were 80.86%, 84.23% and 83.05%, respectively; the corresponding values for SOS were 50.60%, 73.68% and 66.67%. The area under the receiver operating characteristic curve of the adjusted MCNN method was also higher than that of SOS (0.846 vs. 0.679). In conclusion, our study indicates that the MCNN method may be more accurate than the conventional SOS method. The MCNN tool and ultrasound RF signal analysis are promising future developmental directions for QUS in screening for osteoporosis.

Development of a manufacturer-independent convolutional neural network for the automated identification of vertebral compression fractures in vertebral fracture assessment images using active learning

BACKGROUND

Convolutional neural networks (CNNs) can identify vertebral compression fractures in GE vertebral fracture assessment (VFA) images with high balanced accuracy, but performance against Hologic VFAs is unknown. To obtain good classification performance, supervised machine learning requires balanced and labeled training data. Active learning is an iterative data annotation process with the ability to reduce the cost of labeling medical image data and reduce class imbalance.

PURPOSE

To train CNNs to identify vertebral fractures in Hologic VFAs using an active learning approach, and evaluate the ability of CNNs to generalize to both Hologic and GE VFA images.

METHODS

VFAs were obtained from the OsteoLaus Study (labeled Hologic Discovery A, n = 2726), the Manitoba Bone Mineral Density Program (labeled GE Prodigy and iDXA, n = 12,742), and the Canadian Longitudinal Study on Aging (CLSA, unlabeled Hologic Discovery A, n = 17,190). Unlabeled CLSA VFAs were split into five equal-sized partitions (n = 3438) and reviewed sequentially using active learning. Based on predicted fracture probability, 17.6% (n = 3032) of the unlabeled VFAs were selected for expert review using the modified algorithm-based qualitative (mABQ) method. CNNs were simultaneously trained on Hologic, GE dual-energy and GE single-energy VFAs. Two ensemble CNNs were constructed using the maximum and mean predicted probability from six separately trained CNNs that differed due to stochastic variation. CNNs were evaluated against the OsteoLaus validation set (n = 408) during the active learning process; ensemble performance was measured against the OsteoLaus test set (n = 819).

RESULTS

The baseline CNN, prior to active learning, achieved 55.0% sensitivity, 97.9% specificity, 57.9% positive predictive value (PPV), F1-score 56.4%. Through active learning, 2942 CLSA Hologic VFAs (492 fractures) were added to the training data-increasing the proportion of Hologic VFAs with fractures from 4.2% to 12.5%. With active learning, CNN performance improved to 80.0% sensitivity, 99.7% specificity, 94.1% PPV, F1-score 86.5%. The CNN maximum ensemble achieved 91.9% sensitivity (100% for grade 3 and 95.5% for grade 2 fractures), 99.0% specificity, 81.0% PPV, F1-score 86.1%.

CONCLUSION

Simultaneously training on a composite dataset consisting of both Hologic and GE VFAs allowed for the development of a single manufacturer-independent CNN that generalized to both scanner types with good classification performance. Active learning can reduce class imbalance and produce an effective medical image classifier while only labeling a subset of available unlabeled image data-thereby reducing the time and cost required to train a machine learning model.

Efficacy and Safety of Romosozumab Among Postmenopausal Women With Osteoporosis and Mild-to-Moderate Chronic Kidney Disease

Patients with osteoporosis and chronic kidney disease (CKD) are at increased risk of fracture and associated negative outcomes, including increased mortality. The present post hoc analysis of two randomized, multicenter, phase 3 clinical trials-Fracture Study in Postmenopausal Women with Osteoporosis (FRAME) and Active-Controlled Fracture Study in Postmenopausal Women with Osteoporosis at High Risk (ARCH)-investigated the efficacy and safety of romosozumab in postmenopausal women with osteoporosis and mild-to-moderate CKD. The analysis included data from 7147 patients from FRAME and 4077 from ARCH. Eighty-one percent of patients from FRAME and 85% from ARCH had mild or moderate reduction in estimated glomerular filtration rate (eGFR) at baseline, and part of this reduction is likely age related. During the 1-year double-blind phases of the trials, patients received romosozumab 210 mg sc or placebo monthly in FRAME and romosozumab 210 mg sc monthly or alendronate 70 mg po weekly in ARCH. Bone mineral density (BMD) at the lumbar spine, total hip, and femoral neck and vertebral and nonvertebral fractures were assessed at baseline and month 12. In both trials, the least-square mean percent change from baseline BMD was significantly greater in the romosozumab groups versus controls across all kidney function categories at month 12. Romosozumab reduced the relative risk of new vertebral fractures at month 12 among patients with eGFR of 30-59, 60-89, and ≥90 mL/min by 72% (95% confidence interval [CI] 14-91; p = 0.017), 70% (40-85; p < 0.001), and 84% (30-96; p = 0.005), respectively, in FRAME versus placebo, and by 51% (5-75; p = 0.04), 19% (-28 to 49; p = 0.39), and 57% (1-81, p = 0.04), respectively, in ARCH versus alendronate. Incidences of adverse events, asymptomatic decreases in serum calcium, and evolution of kidney function during the studies were similar across all baseline kidney function groups. Romosozumab is an effective treatment option for postmenopausal women with osteoporosis and mild-to-moderate reduction in kidney function, with a similar safety profile across different levels of kidney function. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Update on subclinical thyroid dysfunction

Subclinical thyroid dysfunction is defined by serum thyroid-stimulating hormone (TSH) levels either greater or less than the reference range with normal thyroxine (T4) concentrations, and consists of subclinical hypothyroidism (SCH) and subclinical hyperthyroidism (SCHyper). For the proper diagnosis of SCH, it is most important to be able to correctly evaluate the serum TSH levels, which have numerous unique characteristics. We also need to be versed in TSH harmonization, which was recently launched world-wide. In this review, we will attempt to determine the best clinical approaches to the treatment of subclinical thyroid dysfunction based on recent guidelines published from several countries and novel findings of several recent large-scale clinical studies.

Vitamin D and Visceral Obesity in Humans: What Should Clinicians Know?

The extraskeletal effect of vitamin D on adipose tissue biology and modulation in human obesity is of great interest and has been extensively investigated. Current evidence from preclinical and clinical studies in human adipose tissue suggests that the anti-inflammatory effects of vitamin D are evident and consistent, whereas the effects of vitamin D on adipocyte differentiation, adipogenesis, and energy metabolism and the effects of vitamin D supplementation on adipokine levels are inconclusive. Interventional studies related to medical and surgical weight loss in humans have shown small or no improvement in vitamin D status. Additionally, the benefit of vitamin D supplementation for the reduction in visceral adipose tissue has only been demonstrated in a few studies. Overall, the findings on the relationship between vitamin D and visceral adipose tissue in humans are still inconclusive. Further studies are required to confirm the beneficial effects of vitamin D on ameliorating adipose tissue dysfunction.

Effects of Metformin on Bone Mineral Density and Adiposity-Associated Pathways in Animal Models with Type 2 Diabetes Mellitus: A Systematic Review

Recently, there have been investigations on metformin (Met) as a potential treatment for bone diseases such as osteoporosis, as researchers have outlined that type 2 diabetes mellitus (T2DM) poses an increased risk of fractures. Hence, this systematic review was conducted according to the 2020 PRISMA guidelines to evaluate the evidence that supports the bone-protective effects of metformin on male animal models with T2DM. Five databases—Google Scholar, PubMed, Wiley Online Library, SCOPUS, and ScienceDirect—were used to search for original randomized controlled trials published in English with relevant keywords. The search identified 18 articles that matched the inclusion criteria and illustrated the effects of Met on bone. This study demonstrates that Met improved bone density and reduced the effects of T2DM on adiposity formation in the animal models. Further research is needed to pinpoint the optimal dosage of Met required to exhibit these therapeutic effects.

Osteoporosis in Indian Patients Undergoing Elective Arthroplasty and Spinal Procedures: An Observational Study

Background This is an observational study conducted to determine the prevalence of osteoporosis and osteopenia in patients undergoing elective arthroplasty and spinal procedures in India. Methods This observational, multicentre study included both male and female patients. Their bone mineral density and fracture risk were measured using dual-energy x-ray absorptiometry (DEXA) and Fracture Risk Assessment Tool (FRAX®: Centre for Metabolic Bone Diseases, University of Sheffield, UK), respectively, in compliance with the guidelines for Good Epidemiological Practice (ISRCTN: 14543098). Results The study revealed that majority (76.4%; 97/127) of the patients had low BMD; over one-third had osteoporosis (39.4%; 50/127) or osteopenia (37%; 47/127). Among those undergoing total knee replacement (TKR)/total hip replacement (THR), majority (75.6%; 59/78) had low BMD (osteoporosis: 38.5% {30/78}; osteopenia: 37.2% {29/78}). Among the patients undergoing spinal procedures, all except two (93.10%; 27/29) had low BMD, two-thirds had osteoporosis (65.5%; 19/29), and around one-fourth had osteopenia (27.6%; 8/29). Radial BMD measurements showed higher prevalence of osteoporosis and osteopenia. Based on FRAX score, nearly 30% of patients were at a high risk of hip fracture in the next 10 years. As per National Osteoporosis Foundation (NOF) guidelines, most (59.79%; 58/97) patients with osteoporosis/osteopenia met criteria for pharmacological treatment. Conclusions Regular preoperative bone health evaluation should be adopted and osteoporosis/osteopenia patients should be adequately managed pharmacologically in India.

Reproducibility and Accuracy of the Radiofrequency Echographic Multi-Spectrometry for Femoral Mineral Density Estimation and Discriminative Power of the Femoral Fragility Score in Patients with Primary and Disuse-Related Osteoporosis

We aimed to investigate the reproducibility and accuracy of Radiofrequency Echographic Multi-Spectrometry (REMS) for femoral BMD estimation and the reproducibility and discriminative power of the REMS-derived femoral fragility score. 175 patients with primary and disuse-related osteoporosis were recruited: one femoral Dual-energy X-ray Absorptiometry (DXA) scan and two femoral REMS scans were acquired. No significant test—retest differences were observed for all REMS-derived variables. The diagnostic concordance between DXA and REMS was 63% (Cohen’s kappa = 0.31) in patients with primary osteoporosis and 13% (Cohen’s kappa: −0.04) in patients with disuse-related osteoporosis. No significant difference was observed between REMS and DXA for either femoral neck BMD (mean difference between REMS and DXA: −0.015 g/cm²) or total femur BMD (mean difference: −0.004 g/cm²) in patients with primary osteoporosis. Significant differences between the two techniques were observed in patients with disuse-related osteoporosis (femoral neck BMD difference: 0.136 g/cm²; total femur BMD difference: 0.236 g/cm²). Statistically significant differences in the fragility score were obtained between the fractured and non-fractured patients for both populations. In conclusion, REMS showed excellent test-retest reproducibility, but the diagnostic concordance between DXA and REMS was between minimal and poor. Further studies are required to improve the REMS—derived estimation of femoral BMD.

Sex-specific bi‑directional association between osteoporosis and depression from the national representative data of South Korea

Both osteoporosis and depression are major health threats, but their interrelationship is not clear. This study elucidated the associations between osteoporosis and depression while considering the temporal sequence of the diagnoses. In this cross-sectional study, data were extracted from the Korean National Health and Nutrition Examination Surveys (2007-2009 and 2015-2019, n = 29,045). Osteoporosis and depression were defined by diagnoses thereof. The odds ratio (OR) of the incident osteoporosis among depression patients without a history of osteoporosis was calculated by multivariable logistic regression adjusted for potential confounders. A reverse association was also assessed. Participants were additionally stratified by their sex and age. As a result, male depression patients aged under 50 years showed higher ORs for osteoporosis than those without depression (OR 9.16, 95% CI 1.78-47.18). Female osteoporosis patients showed lower ORs for depression than those without osteoporosis (OR 0.71, 95% CI 0.58-0.88), especially in women aged 50 years and older. In the sensitivity analysis, the same results were obtained in women by their menopause status. Depression has a strong positive association with the occurrence of osteoporosis in young male adults, and osteoporosis has a negative association with the occurrence of depression in female adults.

Osteoporosis Diagnosis, Management, and Referral Practice After Fragility Fractures

PURPOSE OF REVIEW

The purpose of this manuscript is to review the current diagnosis, management, and referral practices of patients with osteoporosis after a fragility fracture from the orthopedic surgeon's perspective.

RECENT FINDINGS

Effective treatments are available for osteoporosis that significantly decrease the risk of additional fractures. Despite recommendations for improved post-fragility fracture osteoporosis management, the rate of diagnosis and treatment is still unacceptably low. Patients sustaining a low-energy fracture should be evaluated for osteoporosis with discussion of beginning pharmacological treatment. Antiresorptive and anabolic agents are available treatment options. Fracture Liaison Services can help to coordinate the care of these patients and improve the rate of diagnosis and initiation of therapy. Dartmouth-Hitchcock is working to improve the bone health for our patients utilizing a multidisciplinary team-based approach. This process is intended to lead to increased recognition of osteoporosis within our institution and close the capture gap between hospital discharge and initiation of osteoporosis pharmacotherapy.

Romosozumab and antiresorptive treatment: the importance of treatment sequence

To evaluate whether treatment sequence affects romosozumab response, this analysis reviewed studies where romosozumab was administered before or following an antiresorptive (alendronate or denosumab). Initial treatment with romosozumab followed by an antiresorptive resulted in larger increases in bone mineral density of both hip and spine compared with the reverse sequence.

INTRODUCTION

Teriparatide followed by an antiresorptive increases bone mineral density (BMD) more than using an antiresorptive first. To evaluate whether treatment sequence affects romosozumab response, we reviewed randomized clinical trials where romosozumab was administered before (ARCH, FRAME) or following (STRUCTURE, Phase 2 extension) an antiresorptive (alendronate or denosumab, respectively).

METHODS

We evaluated BMD percentage change for total hip (TH) and lumbar spine (LS) and response rates (BMD gains ≥ 3% and ≥ 6%) at years 1 and 2 (except STRUCTURE with only 1-year data available).

RESULTS

With 1-year romosozumab initial therapy in ARCH and FRAME, TH BMD increased 6.2% and 6.0%, and LS BMD increased 13.7% and 13.1%, respectively. When romosozumab was administered for 1 year after alendronate (STRUCTURE) or denosumab (Phase 2 extension), TH BMD increased 2.9% and 0.9%, respectively, and LS BMD increased 9.8% and 5.3%, respectively. Over 2 years, TH and LS BMD increased 7.1% and 15.2% with romosozumab/alendronate, 8.5% and 16.6% with romosozumab/denosumab, and 3.8% and 11.5% with denosumab/romosozumab, respectively. A greater proportion of patients achieved BMD gains ≥ 6% when romosozumab was used first, particularly for TH, versus the reverse sequence (69% after romosozumab/denosumab; 15% after denosumab/romosozumab).

CONCLUSION

In this study, larger mean BMD increases and greater BMD responder rates were achieved when romosozumab was used before, versus after, an antiresorptive agent. Since BMD on treatment is a strong surrogate for bone strength and fracture risk, this analysis supports the thesis that initial treatment with romosozumab followed by an antiresorptive will result in greater efficacy versus the reverse sequence.

Long-Term Sex-Specific Effects of Cadmium Exposure on Osteoporosis and Bone Density: A 10-Year Community-Based Cohort Study

This study explored the long-term effects of cadmium (Cd) exposure on osteoporosis incidence and bone mineral density (BMD). This retrospective cohort study included men aged ≥50 years and post-menopausal women from the 2001−2002 Korea Genome and Epidemiology Study. Participants previously diagnosed with osteoporosis were excluded. Blood Cd concentrations were measured and categorized as <0.5, 0.5−1.0, and >1.0 μg/L. BMD was measured using quantitative ultrasound. Osteoporosis was diagnosed when the T-score was ≤−2.5. Confounders that affect exposure and outcome were controlled. Osteoporosis incidence and differences in BMD (ΔBMD) were assessed until 2012. The osteoporosis incidence among 243 participants who were followed up for an average of 6.3 years was 22.2%. In all the participants, a dose−response relationship was observed between blood Cd and incident osteoporosis and ΔBMD (both p-for-trend < 0.01). After adjusting for age, sex, smoking, physical activity, body mass index, creatinine, and baseline BMD, a blood Cd concentration of >1.0 μg/L was an independent risk factor for incident osteoporosis and decrements in ΔBMD. In women, blood Cd concentrations of >0.5 μg/L increased the risk for osteoporosis. Exposure to Cd prospectively increases the risk for osteoporosis and decrements of ΔBMD, particularly in women, even in lower doses of Cd.

Secondary Osteoporosis and Metabolic Bone Diseases

Fragility fracture is a worldwide problem and a main cause of disability and impaired quality of life. It is primarily caused by osteoporosis, characterized by impaired bone quantity and or quality. Proper diagnosis of osteoporosis is essential for prevention of fragility fractures. Osteoporosis can be primary in postmenopausal women because of estrogen deficiency. Secondary forms of osteoporosis are not uncommon in both men and women. Most systemic illnesses and organ dysfunction can lead to osteoporosis. The kidney plays a crucial role in maintaining physiological bone homeostasis by controlling minerals, electrolytes, acid-base, vitamin D and parathyroid function. Chronic kidney disease with its uremic milieu disturbs this balance, leading to renal osteodystrophy. Diabetes mellitus represents the most common secondary cause of osteoporosis. Thyroid and parathyroid disorders can dysregulate the osteoblast/osteoclast functions. Gastrointestinal disorders, malnutrition and malabsorption can result in mineral and vitamin D deficiencies and bone loss. Patients with chronic liver disease have a higher risk of fracture due to hepatic osteodystrophy. Proinflammatory cytokines in infectious, autoimmune, and hematological disorders can stimulate osteoclastogenesis, leading to osteoporosis. Moreover, drug-induced osteoporosis is not uncommon. In this review, we focus on causes, pathogenesis, and management of secondary osteoporosis.

How to initiate and develop Fracture Liaison Services (FLS). Recommendations from the IOF Capture the Fracture® FLS Mentors in Brazil

Expected number of fragility fractures in Brazil, raising the healthcare prioritization for interventions that reduce fracture risk. An FLS is dedicated to managing patient with fragility fracture to reduce risk of another fracture. We review FLSs cost-effectiveness and describe key components to effectively set up FLS in Brazil.

PURPOSE

To create a guideline to show health professionals, hospital managers, and stakeholders in Brazil the importance of secondary fracture prevention and how to implement a Fracture Liaison Service.

METHODS

We review the cost-effectiveness for FLSs in Brazil. We describe the key components needed to set up an effective FLS including methods for identification, investigation, treatment indication, including bone drugs, supplementation, physical activity, fall prevention, and monitoring. The staffing of FLSs, value of regional clinical networks and quality improvement are also described as a guide for healthcare professionals and decision makers in Brazil.

RESULTS

An FLS is a service dedicated to identifying, assessing, recommending treatment, and monitoring patient who present with a fragility fracture reducing the risk of another fracture. FLS has been implemented in Brazil since 2012 overcoming a large geography and a complex health system. Even the limitations, restrictions, differences, and characteristics of each region, it is possible for health institutions to initiate an FLS, adapted to own available resources and meet the stages of identification, investigation, treatment, and monitoring.

CONCLUSION

The peculiarity of the Brazilian healthcare system means FLS implementation needs to be tailored to local reality. However, even with limitations, any attempt to capture patients who suffer a fracture due to bone fragility is effective and reduces the risk of further fractures.

Outcomes post fragility fracture among members of an integrated healthcare organization

This study highlights an unmet need in osteoporosis management, suggesting that beyond bone mineral density and fracture history, gender, fracture type, and age should be considered for fracture risk assessment. Following fragility fracture, men, patients with a spine or hip fracture, and those aged ≥ 65 have a higher disease burden.

INTRODUCTION

The objective of this study was to characterize osteoporosis-related fracture incidence and identify predictors of subsequent fractures and mortality.

METHODS

This retrospective cohort study, conducted within Kaiser Permanente Southern California, included patients aged ≥ 50 years with qualifying fractures from 1/1/2007 to 12/31/2016, identified from diagnosis/procedure codes. Rates for fracture incidence, mortality, and resource utilization in the year post-fracture are reported. Associations between index fracture types and demographic/clinical characteristics, and mortality, subsequent fracture, and rehospitalization outcomes were estimated.

RESULTS

Of 63,755 eligible patients, 66.7% were ≥ 65 years and 69.1% female. Index fractures included nonhip/nonspine (64.4%), hip (25.3%), and spine (10.3%). Age-adjusted subsequent fracture rate/100 person-years was higher for those with an index spine (14.5) versus hip fracture (6.3). Hospitalization rate/100 person-years was highest for patients ≥ 65 (31.8) and for spine fractures (43.5). Men (vs women) had higher age-adjusted rates of hospitalization (19.4; 17.7), emergency room visits (73.8; 66.3), and use of rehabilitation services (31.7; 27.2). The 30-day age-adjusted mortality rate/100 person-years was 46.7, 32.4, and 15.5 for spine, hip, and nonspine/nonhip fractures. The 1-year age-adjusted mortality rate/100 person-years was 14.7 for spine and 15.6 for hip fractures. In multivariable analyses, spine and hip fractures (vs nonhip/nonspine fractures) were significant predictors of 1-year mortality, all-cause and osteoporosis-related hospitalization, and nursing home use (all P-values < 0.0001).

CONCLUSION

Morbidity is high in the year following a fragility fracture and men, patients with a spine or hip fracture, and those aged ≥ 65 have a greater disease burden.

Bone Mineral Density and Trabecular Bone Score in Predicting Vertebral Fractures in Male Employees of the Electricity Generating Authority of Thailand

Purpose

Osteoporotic VF is frequently asymptomatic and affects not only women but also men. Identifying patients at risk is essential for early management and prevention. BMD and the TBS are measurements of bone strength and trabecular microarchitecture, respectively. Their role in VF prediction in men is less well-studied. We determined the BMD and TBS predictive ability for osteoporotic VF in men.

Methods

A total of 115 male participants of the Electricity Generating Authority of Thailand (EGAT) cohorts without a history of VF who completed the baseline BMD and TBS measurements in 2012 and a thoracolumbar spine radiograph in 2017 were recruited. The VF was assessed using the Genant semiquantitative method. Logistic regression analysis was performed to identify factors associated with the fracture. The area under the receiving operator curve (AUC) was analyzed to define VF predictive ability.

Results

Forty subjects (34.78%) had VFs. The unadjusted relative risks (95% confidence interval) for VF for one standard deviation decrease in the TBS and low TBS were 1.319 (1.157-1.506) and 2.347 (1.496-3.682), respectively, and remained significant after BMD and age adjustment. For VF prediction, combined models had a greater AUC than models predicted from a single variable. The use of low TBS, femoral neck BMD, and age provided the best AUC (0.693).

Conclusion

BMD and the TBS could predict osteoporotic VF in male EGAT employees. The use of both BMD and the TBS in the VF prediction process improved predictive ability.

Proximal Femur Responses to Sequential Therapy with Abaloparatide Followed by Alendronate in Postmenopausal Women with Osteoporosis by 3D Modeling of Hip DXA

Previous subgroup analyses from the ACTIVE trial in women with postmenopausal osteoporosis (NCT01343004) using three‐dimensional (3D)‐processing of dual X‐ray absorptiometry (DXA) scans indicated greater increases in total hip cortical volumetric bone mineral density (Ct.vBMD) and estimated indices of hip strength following 18 months of abaloparatide (ABL) versus placebo or teriparatide. The current post hoc analyses describe hip 3D‐DXA data for ACTIVExtend (NCT01657162), in which 18 months of ABL followed by 24 months of alendronate (ABL/ALN) increased hip and spine areal BMD (aBMD) and reduced fracture risk versus placebo (PBO) followed by ALN (PBO/ALN). In an ACTIVExtend subgroup (ABL/ALN, n = 204; PBO/ALN, n = 202), hip DXA scans retrospectively underwent 3D modeling via 3D‐Shaper software. Changes from baseline in cortical and trabecular compartments were calculated for total hip and hip subregions (femoral neck, trochanter, and shaft). Estimated strength indices comprising cross‐sectional moment of inertia, section modulus, and buckling ratio were calculated for each hip subregion. Correlations between bone turnover marker levels at the time of alendronate initiation and subsequent BMD gains with alendronate were also investigated within each group. Total hip trabecular and cortical 3D‐DXA parameters increased from baseline in both groups (all p < 0.001), with greater average increases for ABL/ALN versus PBO/ALN (trabecular vBMD: 10.87% versus 4.3%; cortical thickness: 2.32% versus 1.14%; Ct.vBMD: 3.41% versus 1.86%; cortical surface BMD: 5.82% versus 3.0%; all p < 0.001). Strength indices in the ABL/ALN group improved in all subregions versus baseline (all p < 0.0001) and versus PBO/ALN (all p < 0.02). In the ABL/ALN group, collagen type I N‐terminal propeptide (P1NP) levels at the time of alendronate initiation correlated with subsequent percent changes in all 3D‐DXA parameters with 24 months of alendronate therapy. In conclusion, sequential ABL/ALN or PBO/ALN treatment improves trabecular and cortical 3D‐DXA parameters at the hip, as well as strength indices of hip subregions, with greater increases with ABL/ALN versus PBO/ALN. © 2022 Radius Health, Inc. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Disparities in osteoporosis care among postmenopausal women in the United States

Osteoporosis and fragility fractures result in significant morbidity and mortality and contribute to substantial healthcare costs. Despite being a treatable disease, osteoporosis remains both underdiagnosed and undertreated in the US general population, with significant disparities in care between non-White and White women. These disparities are evident from screening to post-fracture treatment. Non-White women are less likely to be screened for osteoporosis, to be prescribed pharmacotherapy, or to receive treatment post-fracture; furthermore, the mortality rate after fracture is higher in non-White women. Given existing diagnostic and treatment disparities, additional studies and interventions are needed to optimize the bone health of Asian, Black, Hispanic, and Native American women, and to reduce morbidity and mortality from osteoporosis and fragility fractures.

Heavy clinical and economic burden of osteoporotic fracture among elderly female Medicare beneficiaries

We comprehensively described elderly Medicare women with an outpatient visit in 2011 and fracture within 2 years before. These women were at very high risk for subsequent fracture and high healthcare utilization and cost, especially those with vertebral or multiple fractures. However, rates of fracture prevention treatments were low.

INTRODUCTION

Postmenopausal women with osteoporosis are stratified to high and very-high fracture risk categories, and this categorization drives algorithms for osteoporosis management in osteoporosis treatment guidelines. This study comprehensively describes a very-high-risk cohort.

METHODS

This retrospective cohort study used the Medicare 20% database; elderly women with an outpatient visit in 2011 and fracture within 2 years before the visit were included. Outcomes included fracture risk, all-cause and fracture-related healthcare resource utilization and cost, and osteoporosis medication use in the 5 years after the visit.

RESULTS

Overall, 43,193 patients were included. The 5-year probability was 0.36 for major fracture and 0.11 and 0.17 for hip fracture and vertebral fracture, respectively, much higher than the guidelines' 10-year probability thresholds for very-high-risk (0.3 for major fracture, 0.045 for hip fracture). Rates of hospitalizations, emergency department visits or observation stays, and skilled nursing facility stays in year 1 were 53.7, 57.0, and 18.8 per 100 patient-years, respectively, decreasing slightly in subsequent years. Mean healthcare cost was $23,700 in year 1, decreasing to $18,500 in year 5. About 29.1% of patients received osteoporosis medications in year 1, decreasing to 16.9% by year 5. Rates for all outcomes, especially fractures, were much higher among vertebral and multiple fracture cohorts.

CONCLUSION

Elderly women with a fracture within last 2 years were at very-high-risk for subsequent fracture and high healthcare utilization and cost, especially those with vertebral or multiple fractures. However, rates of fracture prevention treatments were low. More effort is needed to identify and treat patients at very-high-risk for fracture.

miR-29cb2 promotes angiogenesis and osteogenesis by inhibiting HIF-3α in bone

Coordination between osteogenesis and angiogenesis is required for bone homeostasis. Here, we show that miR-29cb2 is a bone-specific miRNA and plays critical roles on angiogenesis-osteogenesis coupling during bone remodeling. Mice with deletion of miR-29cb2 exhibit osteopenic phenotypes and osteoblast impairment, accompanied by pronounced decreases in specific H vessels. The decrease in bone miR-29cb2 was associated with pathological ovariectomy stimuli. Mechanistically, hypoxia-inducible factor (HIF)-3α, as a target for miR-29cb2, inhibits HIF-1α activity by competitively bonding with HIF-1β. Notably, miR-29cb2 in peripheral blood (PB) nearly is undetectable in sham and significantly increases in ovariectomy mice. Further evaluation from osteoporosis patients demonstrates similar signatures. ROC analysis shows miR-29cb2 in PB has higher sensitivity and specificity for diagnosing osteoporosis when compared with four clinical biomarkers. Collectively, these findings reveal that miR-29cb2 is essential for bone remodeling by inhibiting HIF-3α and elevated bone-specific miR-29cb2 in PB, which may be a promising biomarker for bone loss.

PFN1 Gene Polymorphisms and the Bone Mineral Density Response to Alendronate Therapy in Postmenopausal Chinese Women with Low Bone Mass

Purpose

Alendronate is a widely used anti-osteoporotic drug. PFN1 gene is a newly identified early-onset Paget’s disease pathogenic gene. The purpose of this study is to study whether the genetic variations in this gene affect the clinical efficacy of alendronate in postmenopausal Chinese women with low bone mass.

Patients and Methods

Seven single nucleotide polymorphisms in PFN1 gene were genotyped. A total of 500 postmenopausal women with osteoporosis or osteopenia were included. All participants were treated with weekly alendronate 70 mg for 12 months. A total of 466 subjects completed the follow-up. Bone mineral density (BMD) of lumbar spine, femoral neck and total hip were measured at baseline and after treatment.

Results

After 12 months of treatment, the BMD of lumbar spine, femoral neck and total hip all increased significantly (all P < 0.001), with an average increase of 4.72 ± 5.31%, 2.08 ± 4.45%, and 2.42 ± 3.46%, respectively. At baseline, there were no significant differences in BMD at lumbar spine, femoral neck and total hip between different genotype groups (P > 0.05). We failed to identify any significant association between the genotypes or haplotypes of PFN1 and the BMD response to alendronate therapy.

Conclusion

Genetic polymorphisms of PFN1 may not be a major contributor to the therapeutic response to alendronate treatment in Chinese women with low bone mass.

Hip fracture predicts subsequent hip fracture: a retrospective observational study to support a call to early hip fracture prevention efforts in post-fracture patients

In this real-world retrospective cohort, subsequent hip fracture occurred in one in four patients with any initial fracture, most often after hip fracture, on average within 1.5 years. These data support the need for early post-fracture interventions to help reduce imminent hip fracture risk and high societal and humanistic costs.

PURPOSE

This large retrospective cohort study aimed to provide hip fracture data, in the context of other fractures, to help inform efforts related to hip fracture prevention focusing on post-fracture patients.

METHODS

A cohort of 115,776 patients (72.3% female) aged > 65 (median age 81) with an index fracture occurring at skeletal sites related to age-related bone loss between January 1, 2011, and March 31, 2015, was identified using health services data from Ontario, Canada, and followed until March 31, 2017.

RESULTS

Hip fracture was the most common second fracture (27.8%), occurring in ≥ 19% of cases after each index fracture site and most frequently (33.0%) after hip index fracture. Median time to a second fracture of the hip was ~ 1.5 years post-index event. Patients with index hip fracture contributed the most to fracture-related initial surgeries (64.1%) and post-surgery complications (71.9%) and had the second-highest total mean healthcare cost per patient in the first year after index fracture ($62,793 ± 44,438). One-year mortality (any cause) after index hip fracture was 26.2% vs. 15.9% in the entire cohort, and 25.9% after second hip fracture.

CONCLUSION

A second fracture at the hip was observed in one in four patients after any index fracture and in one in three patients with an index hip fracture, on average within 1.5 years. Index hip fracture was associated with high mortality and post-surgery complication rates and healthcare costs relative to other fractures. These data support focusing on early hip fracture prevention efforts in post-fracture patients.

Denosumab in the Treatment of Osteoporosis: 10 Years Later: A Narrative Review

The fully human monoclonal antibody denosumab was approved for treatment of osteoporosis in 2010 on the basis of its potent antiresorptive activity, which produces clinically meaningful increases in bone mineral density (BMD) and reduces fracture risk at key skeletal sites. At that time, questions remained regarding the long-term safety and efficacy of this receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor; and with clinical experience, new questions have arisen regarding its optimal use. Here, we examine these questions through the lens of data from the FREEDOM trial program and other studies to determine where denosumab fits in the osteoporosis treatment landscape. Clinical consensus and evidentiary support have grown for denosumab as a highly effective anti-osteoporosis therapy for patients at high risk of fracture. In the 10-year FREEDOM Extension study, denosumab treatment produced progressive incremental increases in BMD, sustained low rates of vertebral fracture, and further reduction in nonvertebral fracture risk without increased risk of infection, cancer, or immunogenicity. There was no evidence that suppression of bone turnover or mineralization was excessive, and rates of osteonecrosis of the jaw (ONJ) and atypical femoral fracture (AFF) were very low. It is now recognized, however, that transitioning to another anti-osteoporosis therapy after denosumab discontinuation is essential to mitigate a transient rebound of bone turnover causing rapid BMD loss and increased risk of multiple vertebral fractures (MVFs). Taken together, the available data show that denosumab has a favorable benefit/risk profile and is a versatile agent for preventing osteoporotic fractures in the short and long term.

Romosozumab reduces incidence of new vertebral fractures across severity grades among postmenopausal women with osteoporosis

Vertebral fractures (VFs) are the most common type of osteoporotic fracture, and their prevalence and severity are key risk factors for future fragility fractures. Here, we assess the treatment effect of romosozumab on the incidence of new on-study VFs according to Genant severity grades (mild, moderate, and severe). Data are reported from two phase 3 clinical studies for patients who received romosozumab versus placebo through 12 months, followed by denosumab through 24 months (FRAME: NCT01575834), and for patients who received romosozumab through 12 months, followed by alendronate through 24 months, versus alendronate only through 24 months (ARCH: NCT01631214). The treatment effect of romosozumab is reported for all included patients, and for patients with prevalent and severe baseline VFs. The incidence of new moderate-or-severe VFs was reduced through 12 months for patients treated with romosozumab versus placebo (FRAME; 0.25% versus 1.42%, respectively; p < 0.001) or alendronate (ARCH; 2.78% versus 4.00%, respectively; p = 0.042). Furthermore, the treatment effect of romosozumab on the incidence of new VFs across moderate and severe severity grades was independent of baseline VF prevalence or severity; through 12 months, consistent reductions in new moderate-or-severe VFs were observed regardless of prevalent (FRAME; p = 0.18) or severe (ARCH; p = 0.52) VFs at baseline. Reductions in the incidence of new moderate and severe VFs were sustained through 24 months, after transition from romosozumab to denosumab or alendronate, independent of baseline VF prevalence or severity; no significant interactions were observed between the incidence of new moderate-or-severe VFs and the presence of prevalent (FRAME; p = 0.81) or severe (ARCH; p = 0.99) VFs at baseline. With increasing recommendations for initial treatment with bone-forming agents for postmenopausal women with osteoporosis, these analyses will help to inform treatment decisions for patients at very high risk of VF.

Deep learning for screening primary osteopenia and osteoporosis using spine radiographs and patient clinical covariates in a Chinese population

PURPOSE

Many high-risk osteopenia and osteoporosis patients remain undiagnosed. We proposed to construct a convolutional neural network model for screening primary osteopenia and osteoporosis based on the lumbar radiographs, and to compare the diagnostic performance of the CNN model adding the clinical covariates with the image model alone.

METHODS

A total of 6,908 participants were collected for analysis, including postmenopausal women and men aged 50-95 years, who performed conventional lumbar x-ray examinations and dual-energy x-ray absorptiometry (DXA) examinations within 3 months. All participants were divided into a training set, a validation set, test set 1, and test set 2 at a ratio of 8:1:1:1. The bone mineral density (BMD) values derived from DXA were applied as the reference standard. A three-class CNN model was developed to classify the patients into normal BMD, osteopenia, and osteoporosis. Moreover, we developed the models integrating the images with clinical covariates (age, gender, and BMI), and explored whether adding clinical data improves diagnostic performance over the image mode alone. The receiver operating characteristic curve analysis was performed for assessing the model performance.

RESULTS

As for classifying osteoporosis, the model based on the anteroposterior+lateral channel performed best, with the area under the curve (AUC) range from 0.909 to 0.937 in three test cohorts. The models with images alone achieved moderate sensitivity in classifying osteopenia, in which the highest AUC achieved 0.785. The performance of models integrating images with clinical data shows a slight improvement over models with anteroposterior or lateral images input alone for diagnosing osteoporosis, in which the AUC increased about 2%-4%. Regarding categorizing osteopenia and the normal BMD, the proposed models integrating images with clinical data also outperformed the models with images solely.

CONCLUSION

The deep learning-based approach could screen osteoporosis and osteopenia based on lumbar radiographs.

Postmenopausal osteoporosis: risk evaluation and treatment options

Postmenopausal osteoporosis is a chronic progressive condition characterized by reduced bone mass and impaired bone quality, leading to an increased risk of fragility fractures. Osteoporotic fractures reduce quality of life and are associated with high morbidity, mortality and economic burden. Primary and secondary prevention interventions are always recommended starting from the premenopausal age, in women after menopause, however, it is essential to develop a long-term intervention strategy that allows to identify patients at high risk of fracture and the choice of therapy based on the estimated risk. This narrative review described the tools for layering the management approach in relation to low, high and very high fracture risk. Several medications are now available for the treatment of osteoporosis and the prevention of fractures; the knowledge of the efficacy, safety and additional benefits profile of the individual preparations allows an appropriate choice between the different drugs available and the possibility of adapting the prescription to the lifetime fracture risk spectrum. From the literature it emerges that menopausal hormone therapy (MHT), TSEC combination and SERMs can be drugs of choice to counteract postmenopausal bone loss in younger women or at low risk of fracture, while bisphosphonates and denosumab are appropriate for women with high risk or at an older age. Therapy with denosumab and anabolic agents such as teriparatide and romosozumab is particularly indicated for subjects with very high risk of fracture.

Patterns of Teriparatide and Sequential Antiresorptive Agent Treatment Among Elderly Female Medicare Beneficiaries

The 2020 American Association of Clinical Endocrinologists guidelines for assessing osteoporosis among postmenopausal women stratified postmenopausal women with osteoporosis to "high" and "very-high" fracture risk categories and recommended anabolic agents as initial therapy followed by an antiresorptive agent. Switching the order can blunt the effect of anabolic agents, and failing to follow with an antiresorptive can lead to loss of bone generated by the anabolic agent. It would be helpful to understand the real-world prescribing patterns of anabolic agents. Using the 2010-2015 Medicare 100% osteoporosis database, we assessed patient profiles, teriparatide prescribers, persistence of teriparatide therapy, and antiresorptive agent use after teriparatide discontinuation among elderly women who initiated teriparatide from 2011 to 2013. This study included 14,786 patients. In the year before teriparatide initiation, 30.0% of them had a fracture, 67.6% had a dual energy x-ray absorptiometry scan, 74.4% had a diagnosis of osteoporosis, and 47.9% used antiresorptive agents (non-naïve teriparatide users). Among those who had fractures, 49.4% initiated teriparatide within 3 months postfracture. Teriparatide was prescribed for 37% of users by primary care doctors, 19% by rheumatologists, 13% by endocrinologists, and 7.0% by orthopedists. Median time of teriparatide use was 7.2 months. After teriparatide discontinuation, 40.8% switched to antiresorptive agents (31.9% among naïve teriparatide users, 50.5% among non-naïve users). Among switchers, 42.5% switched within 60 days, 50.5% switched to denosumab, and 31.6% switched to oral bisphosphonates. This study of real-world prescribing data found that about half of teriparatide users switched from an antiresorptive agent, and less than half switched to antiresorptive agents after teriparatide discontinuation. Persistence of teriparatide use was suboptimal. In the management of postmenopausal osteoporosis, increasing the persistence of teriparatide use and improving the appropriate treatment sequence of anabolic and antiresorptive drugs are critical to maximizing gains in bone mass, providing the greatest protection against fractures. © 2021 American Society for Bone and Mineral Research (ASBMR).

Systems-Level Opportunities in the Management of Primary Hyperparathyroidism: An Informatics-based Assessment

CONTEXT

Primary hyperparathyroidism (PHPT), a leading cause of hypercalcemia and secondary osteoporosis, is underdiagnosed.

OBJECTIVE

This work aims to establish a foundation for an electronic medical record-based intervention that would prompt serum parathyroid hormone (PTH) assessment in patients with persistent hypercalcemia and identify care gaps in their management.

METHODS

A retrospective cohort study was conducted in a tertiary academic health system of outpatients with persistent hypercalcemia, who were categorized as having classic or normohormonal PHPT. Main outcome measures included the frequencies of serum PTH measurement in patients with persistent hypercalcemia, and their subsequent workup with bone mineral density (BMD) assessment, and ultimately, medical therapy or parathyroidectomy.

RESULTS

Among 3151 patients with persistent hypercalcemia, 1526 (48%) had PTH measured, of whom 1377 (90%) were confirmed to have classic (49%) or normohormonal (41%) PHPT. PTH was measured in 65% of hypercalcemic patients with osteopenia or osteoporosis (P < .001). At median 2-year follow-up, bone density was assessed in 275 (20%) patients with either variant of PHPT (P = .003). Of women aged 50 years or older with classic PHPT, 95 (19%) underwent BMD assessment. Of patients with classic or normohormonal PHPT, 919 patients (67%) met consensus criteria for surgical intervention, though only 143 (15%) underwent parathyroidectomy.

CONCLUSION

Within a large academic health system, more than half of patients with confirmed hypercalcemia were not assessed for PHPT, including many patients with preexisting bone disease. Care gaps in BMD assessment and medical or surgical therapy represent missed opportunities to avoid skeletal and other complications of PHPT.

Romosozumab Followed by Antiresorptive Treatment Increases the Probability of Achieving Bone Mineral Density Treatment Goals

Increases in bone mineral density (BMD) with osteoporosis treatment are associated with reduced fracture risk. Increasing BMD is therefore a goal of osteoporosis therapy. Here, we compare the probability of achieving a T-score of > -2.5 over 3 years at the total hip (TH) or lumbar spine (LS) in women with osteoporosis, ≥55 years of age, after the following treatment sequences: 1 year romosozumab followed by 2 years denosumab (FRAME and FRAME extension trials), 1 year romosozumab followed by 2 years alendronate, or alendronate-only for 3 years (ARCH trial). Probabilities of attaining the BMD target within 1 year of treatment were also determined. At both skeletal sites, in women with a baseline Tscore ≥ -2.7, there was >50% probability of achieving the BMD target with any 3-year regimen. The probability of achieving the target BMD in those with a baseline TH Tscore equal to -3.0 was 61% with romosozumab/denosumab, 38% with romosozumab/alendronate, and 9% with alendronate. In those with a baseline LS Tscore equal to -3.0, the probability of achieving a T-score > -2.5 was 93% with romosozumab/denosumab, 81% with romosozumab/alendronate, and 55% with alendronate. With 1 year of treatment, in patients with a baseline TH T-score equal to -2.7, the probability of reaching the target Tscore with romosozumab was 71% to 78% and 38% with alendronate. For patients with an initial LS T-score equal to -3.0, the probability of achieving the target T-score over 1 year was 85% to 86% with romosozumab and 25% for alendronate. Our findings suggest baseline BMD and the probability of achieving BMD T-score goals are factors to consider when selecting initial treatment for patients with osteoporosis. As baseline T-score falls below -2.7 (TH) and -3.0 (LS), alendronate has <50% likelihood of achieving a BMD goal above osteoporosis range, whereas these probabilities remain relatively high for regimens beginning with romosozumab. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

The first reported fracture liaison service (FLS) for vertebral fractures in China: is muscle the missing gap?

Fracture liaison services (FLS) have been implemented worldwide, but we present one of the first reported experiences in China. Only 1 out of 226 patients had a secondary fracture within 1 year. This serves as a platform to improving solutions and decreasing imminent fractures for future use nationwide in China.

INTRODUCTION

Fracture liaison services (FLS) have been implemented worldwide but we present one of the first reported experiences in China. Vertebral fragility fracture is one of the earliest fracture to occur. The objective of this study was to implement a dedicated fracture service to decrease imminent fractures for future use nationwide in China.

METHODS

Patients 50 years or older with a recent vertebral compression fracture were recruited. All patients were offered investigation with DXA scan and blood taking. Treatment was provided with calcium and vitamin D supplements and denosumab injections. The primary outcome was the imminent fracture rate or the re-fracture rate occurring within 2 years of the initial one. Secondary outcomes were bone mineral density (BMD), treatment initiation, adherence to drug, compliance to follow-up, falls, mortality, pain, quality of life, pain-related disability with Roland-Morris Disability Questionnaire (RMDQ), and Oswestry Disability Index (ODI).

RESULTS

Two hundred twenty-six patients (n = 226) were analyzed. 0.4% (n = 1) had an imminent fracture within 2 years. 11.1% (n = 25) had a fall within 2 years, in which 1 resulted in a major osteoporotic fracture. 7.1% died (n = 16) within the 2-year time period. 97.8% (n = 221) underwent BMD investigation with an initial DXA scan. One hundred percent (n = 226) had treatment initiation and were prescribed with Denosumab injections. 89.8% (n = 203) were compliant and showed complete adherence to drug therapy over the 2 years. Pain, quality of life, and disability were significantly improved.

CONCLUSION

This is the first reported fracture liaison service for vertebral fracture patients reported in China. Future FLS should incorporate muscle and sarcopenic assessments as a routine, and also research on novel interventions in this area would significantly improve patient outcomes.

Romosozumab improves lumbar spine bone mass and bone strength parameters relative to alendronate in postmenopausal women: results from the Active-Controlled Fracture Study in Postmenopausal Women With Osteoporosis at High Risk (ARCH) trial

The Active-Controlled Fracture Study in Postmenopausal Women With Osteoporosis at High Risk (ARCH) trial (NCT01631214; https://clinicaltrials.gov/ct2/show/NCT01631214) showed that romosozumab for 1 year followed by alendronate led to larger areal bone mineral density (aBMD) gains and superior fracture risk reduction versus alendronate alone. aBMD correlates with bone strength but does not capture all determinants of bone strength that might be differentially affected by various osteoporosis therapeutic agents. We therefore used quantitative computed tomography (QCT) and finite element analysis (FEA) to assess changes in lumbar spine volumetric bone mineral density (vBMD), bone volume, bone mineral content (BMC), and bone strength with romosozumab versus alendronate in a subset of ARCH patients. In ARCH, 4093 postmenopausal women with severe osteoporosis received monthly romosozumab 210 mg sc or weekly oral alendronate 70 mg for 12 months, followed by open-label weekly oral alendronate 70 mg for ≥12 months. Of these, 90 (49 romosozumab, 41 alendronate) enrolled in the QCT/FEA imaging substudy. QCT scans at baseline and at months 6, 12, and 24 were assessed to determine changes in integral (total), cortical, and trabecular lumbar spine vBMD and corresponding bone strength by FEA. Additional outcomes assessed include changes in aBMD, bone volume, and BMC. Romosozumab caused greater gains in lumbar spine integral, cortical, and trabecular vBMD and BMC than alendronate at months 6 and 12, with the greater gains maintained upon transition to alendronate through month 24. These improvements were accompanied by significantly greater increases in FEA bone strength (p < 0.001 at all time points). Most newly formed bone was accrued in the cortical compartment, with romosozumab showing larger absolute BMC gains than alendronate (p < 0.001 at all time points). In conclusion, romosozumab significantly improved bone mass and bone strength parameters at the lumbar spine compared with alendronate. These results are consistent with greater vertebral fracture risk reduction observed with romosozumab versus alendronate in ARCH and provide insights into structural determinants of this differential treatment effect. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Efficiency of back muscles training and balance therapy in rehabilitation of patients with osteoporotic vertebral fractures

Medical rehabilitation of patients with osteoporotic vertebral fractures (VF) remains an insufficiently developed topic and requires additional research. Aim of the study was to assess the efficiency of back muscles training and balance therapy in rehabilitation of patients with osteoporotic vertebral fractures. Prospective, interventional, open-label, controlled study in two parallel groups, performed in inpatient department settings at “National Medical Research Center of Rehabilitation and Balneology” during 2018. The study involved 120 patients (11 men and 109 women) aged 40-80 (mean age 65.4±9.1 years) who were admitted for medical rehabilitation for systemic OP and VF. The rehabilitation program in the main group included: 1) Mechanotherapy on the Back-Therapy-Center Dr. Wolf complex with biofeedback (Germany); 2) Balance therapy on a double unstable COBS platform, with biofeedback (Germany); 3) Hydrokinesiotherapy in a pool; 4) Gymnastic exercises (Gorinevskaya-Dreving method). Results. The use of the three-week program of physical rehabilitation using mechanotherapy, balance therapy and special complexes of physiotherapy exercises in the gym and in the pool in patients with osteoporotic VF significantly increases the strength of the muscle corset, helps to eliminate the existing muscle deficit in TE and TF and results in a more physiological distribution of the strength ratio between TE and TF. The rehabilitation program improves the function of static and dynamic balance, both with closed and open eyes, which can be observed in the return of the center of gravity to a physiological position and in improved reaction speed to changes in body position. Usage of mechanotherapeutic methods in rehabilitation of patients with osteoporotic VF is effective for basic motor function improvement and disability reduction.

Diagnosis and Management of Osteoporosis During COVID-19: Systematic Review and Practical Guidance

It is acknowledged that the COVID-19 pandemic has caused profound disruption to the delivery of healthcare services globally. This has affected the management of many long-term conditions including osteoporosis as resources are diverted to cover urgent care. Osteoporosis is a public health concern worldwide and treatment is required for the prevention of further bone loss, deterioration of skeletal micro-architecture, and fragility fractures. This review provides information on how the COVID-19 pandemic has impacted the diagnosis and management of osteoporosis. We also provide clinical recommendations on the adaptation of care pathways based on experience from five referral centres to ensure that patients with osteoporosis are still treated and to reduce the risk of fractures both for the individual patient and on a societal basis. We address the use of the FRAX tool for risk stratification and initiation of osteoporosis treatment and discuss the potential adaptations to treatment pathways in view of limitations on the availability of DXA. We focus on the issues surrounding initiation and maintenance of treatment for patients on parenteral therapies such as zoledronate, denosumab, teriparatide, and romosozumab during the pandemic. The design of these innovative care pathways for the management of patients with osteoporosis may also provide a platform for future improvement to osteoporosis services when routine clinical care resumes.

Potential mechanism of Ziyin Tongluo Formula in the treatment of postmenopausal osteoporosis: based on network pharmacology and ovariectomized rat model

Background

Amending from ancient classic, Ziyin Tongluo Formula (ZYTLF) has been prescribed to treat postmenopausal osteoporosis (PMOP) for decades with good curative effect. However, the possible mechanisms of it are still unknown.

Methods

Ovariectomized rat model was established to validate the therapeutic effect of ZYTLF on PMOP by Micro-CT bone analysis and pathological observation. Subsequently, active ingredients of ZYTLF and corresponding putative targets were identified by online databases. Overlapping genes were first obtained from mining genes associated with PMOP and then overlapped them with the putative targets. Key genes were selected from the multiple constructed and analyzed networks. GO and KEGG pathway enrichment analysis were performed by importing the key genes to the DAVID database. Moreover, validation of the binding association between key targets and their corresponding active compounds were accomplished by AutoDock Tools and other software. Lastly, Enzyme linked immunosorbent assay (Elisa) detection and Western blot analysis were utilized to further explore the possible mechanism of ZYTLF on PMOP.

Results

With 129 target genes interacting with PMOP, 92 active compounds of ZYTLF corresponded to 243 targets, and 50 key genes were chosen. Network analysis revealed the top 10 active ingredients, such as quercetin and kaempferol and the top 50 key genes, such as ERα, p38 MAPK, p-AKT and TGF-β1. Enrichment analysis uncovered multiple signaling pathways, including estrogen signaling pathway, TNF signaling pathway, PI3K-Akt signaling pathway and MAPK signaling pathway. Furthermore, our finding of the foremost active compounds was tightly bound to the core proteins, which were verified by molecular docking analysis. Through experimental studies, we confirmed that the prescription of ZYTLF could ameliorate the OVX-induced bone loss, suppress the osteoclast activity and boost osteoblast ability through experimental studies.

Conclusion

The potential mechanisms and therapeutic effects of ZYTLF against PMOP may be ascribed to inhibition of osteoclast activity, boost of osteoblast activity and enhancement of the expression of ERα.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13020-021-00503-5.

Feasibility of a generalized convolutional neural network for automated identification of vertebral compression fractures: The Manitoba Bone Mineral Density Registry

BACKGROUND

Vertebral fracture assessment (VFA) images are acquired in dual-energy (DE) or single-energy (SE) scan modes. Automated identification of vertebral compression fractures, from VFA images acquired using GE Healthcare scanners in DE mode, has achieved high accuracy through the use of convolutional neural networks (CNNs). Due to differences between DE and SE images, it is uncertain whether CNNs trained on one scan mode will generalize to the other.

PURPOSE

To evaluate the ability of CNNs to generalize between GE DE and GE SE VFA scan modes.

METHODS

12,742 GE VFA images from the Manitoba Bone Mineral Density Program, obtained between 2010 and 2017, were exported in both DE and SE modes. VFAs were classified by imaging specialists as fracture present or absent using the modified algorithm-based qualitative (mABQ) method. VFA scans were randomly divided into independent training (60%), validation (10%), and test (30%) sets. Three CNN models were constructed by training separately on DE only, SE only, and a composite dataset comprised of both SE and DE VFAs. All three trained CNN models were separately evaluated against both SE and DE test datasets.

RESULTS

Good performance was seen for CNNs trained and evaluated on the same scan mode. DE scans used for both training and evaluation (DE/DE) achieved 87.9% sensitivity, 87.4% specificity, and an area under the receiver operating characteristic curve (AUC) of 0.94. SE scans used for both training and evaluation (SE/SE) achieved 78.6% sensitivity, 90.6% specificity, AUC = 0.92. Conversely, CNNs performed poorly when evaluated on scan modes that differed from their training sets (AUC = 0.58). However, a composite CNN trained simultaneously on both SE and DE VFAs gave performance comparable to DE/DE (82.4% sensitivity, 94.3% specificity, AUC = 0.95); and provided improved performance over SE/SE (82.2% sensitivity, 92.3% specificity, AUC = 0.94). Positive predictive value was higher with the composite CNN compared with models trained solely on DE (74.5% vs. 58.7%) or SE VFAs (68.6% vs. 62.9%).

CONCLUSION

CNNs for vertebral fracture identification are highly sensitive to scan mode. Training CNNs on a composite dataset, comprised of both GE DE and GE SE VFAs, allows CNNs to generalize to both scan modes and may facilitate the development of manufacturer-independent machine learning models for vertebral fracture detection.

Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society

OBJECTIVE

To review evidence regarding osteoporosis screening, prevention, diagnosis, and management in the past decade and update the position statement published by The North American Menopause Society (NAMS) in 2010 regarding the management of osteoporosis in postmenopausal women as new therapies and paradigms have become available.

DESIGN

NAMS enlisted a panel of clinician experts in the field of metabolic bone diseases and/or women's health to review and update the 2010 NAMS position statement and recommendations on the basis of new evidence and clinical judgement. The panel's recommendations were reviewed and approved by the NAMS Board of Trustees.

RESULTS

Osteoporosis, especially prevalent in older postmenopausal women, increases the risk of fractures that can be associated with significant morbidity and mortality. Postmenopausal bone loss, related to estrogen deficiency, is the primary contributor to osteoporosis. Other important risk factors for postmenopausal osteoporosis include advanced age, genetics, smoking, thinness, and many diseases and drugs that impair bone health. An evaluation of these risk factors to identify candidates for osteoporosis screening and recommending nonpharmacologic measures such as good nutrition (especially adequate intake of protein, calcium, and vitamin D), regular physical activity, and avoiding smoking and excessive alcohol consumption are appropriate for all postmenopausal women. For women at high risk for osteoporosis, especially perimenopausal women with low bone density and other risk factors, estrogen or other therapies are available to prevent bone loss. For women with osteoporosis and/or other risk factors for fracture, including advanced age and previous fractures, the primary goal of therapy is to prevent new fractures. This is accomplished by combining nonpharmacologic measures, drugs to increase bone density and to improve bone strength, and strategies to reduce fall risk. If pharmacologic therapy is indicated, government-approved options include estrogen agonists/antagonists, bisphosphonates, RANK ligand inhibitors, parathyroid hormone-receptor agonists, and inhibitors of sclerostin.

CONCLUSIONS

Osteoporosis is a common disorder in postmenopausal women. Management of skeletal health in postmenopausal women involves assessing risk factors for fracture, reducing modifiable risk factors through dietary and lifestyle changes, and the use of pharmacologic therapy for patients at significant risk of osteoporosis or fracture. For women with osteoporosis, lifelong management is necessary. Treatment decisions occur continuously over the lifespan of a postmenopausal woman. Decisions must be individualized and should include the patient in the process of shared decision-making.

Bone Mineral Density Trends During the First Year After Laparoscopic Sleeve Gastrectomy-a Cohort Study on 241 Patients

Purpose

Laparoscopic sleeve gastrectomy (LSG) is an effective weight loss procedure, but detrimental effects on bone health have been described. We aimed to assess the dynamics of regional and total bone mineral density (BMD) in a cohort of patients undergoing LSG and to capture gender differences in terms of evolution.

Materials and Methods

We conducted a retrospective study on 241 patients who underwent LSG to determine the regional and total BMD changes at 6 and 12 months after the intervention.

Results

One hundred ten males and 140 females (97 pre-, 43 postmenopausal) were included. Mean baseline body mass index (BMI) was 44.16 ± 6.11 kg/m² in males and 41.60 ± 5.54 kg/m² in females, reaching 28.62 ± 4.26 kg/m² and 27.39 ± 4.2 kg/m², respectively, at 12 months. BMD showed a continuous decline, with significant loss from 6 months postoperatively. There was a positive correlation between BMD and BMI decline at 12 months (r = 0.134, p < 0.05). Total BMD loss at 12 months was significantly greater in males than premenopausal females, independent of BMI variation and age. During the first 6 months, men lost significantly more bone mass than premenopausal and postmenopausal women (BMD variation was 2.62%, 0.27%, 1.58%, respectively). The second period (6–12 months) was similar in all three groups, revealing a further steady (~ 1.4%) BMD decline.

Conclusions

Our results are consistent with previous findings that LSG negatively impacts BMD, stressing the importance of bone health-oriented measures in postoperative care. Moreover, the impact that seems more significant in males warrants future exploration, as it might change clinical practice.

Graphical abstract

Diagnostic, treatment, and follow-up of osteoporosis-position statement of the Latin American Federation of Endocrinology

The Latin American Federation of Endocrinology position statement on osteoporosis was developed by endocrinologists from 9 countries. It encompasses the definition, diagnosis, treatment, and follow-up of the disease, the identification of barriers to healthcare, and proposals to improve the disease care in the region.

INTRODUCTION

There is a gap in the understanding of osteoporosis in Latin America. The objective of this work is to state the position of the Latin American Federation of Endocrinology on osteoporosis care in postmenopausal women to better bridge this gap.

METHODS

An experts' panel was formed comprising of 11 endocrinologists from 9 countries. A data search was conducted with a conceptual approach and data selection was based on the hierarchy of the EBHC pyramid. Unpublished data was considered for local epidemiological data and expert opinion for the identification of barriers to healthcare. An expert consensus based on the Delphi methodology was carried out. Experts were asked to respond on a 5-point Likert Scale to two provided answers to guiding questions.

RESULTS

Consensus was agreed on the answer for the questions with the higher median on the Likert scale and synthetized on 16 statements covering the definition of osteoporosis, diagnostic approach, treatment options, and follow-up. Besides clinical topics, unmet needs in osteoporosis were identified in relation to local epidemiological data, barriers to treatment, and misclassification of programs within health systems.

CONCLUSIONS

Through a process based on recognized methodological tools, FELAEN's position on osteoporosis was developed. This made it possible to state an optimum scenario for the care of the disease and helped to identify knowledge gaps. There is great variability in the approach to osteoporosis in Latin America and barriers in all the stages of healthcare persist.

Bone mineral density response prediction following osteoporosis treatment using machine learning to aid personalized therapy

Osteoporosis is a global health problem for ageing populations. The goals of osteoporosis treatment are to improve bone mineral density (BMD) and prevent fractures. One major obstacle that remains a great challenge to achieve the goals is how to select the best treatment regimen for individual patients. We developed a computational model from 8981 clinical variables, including demographic data, diagnoses, laboratory results, medications, and initial BMD results, taken from 10-year period of electronic medical records to predict BMD response after treatment. We trained 7 machine learning models with 13,562 osteoporosis treatment instances [comprising 5080 (37.46%) inadequate treatment responses and 8482 (62.54%) adequate responses] and selected the best model (Random Forests with area under the receiver operating curve of 0.70, accuracy of 0.69, precision of 0.70, and recall of 0.89) to individually predict treatment responses of 11 therapeutic regimens, then selected the best predicted regimen to compare with the actual regimen. The results showed that the average treatment response of the recommended regimens was 9.54% higher than the actual regimens. In summary, our novel approach using a machine learning-based decision support system is capable of predicting BMD response after osteoporosis treatment and personalising the most appropriate treatment regimen for an individual patient.

Faster Lumbar Spine Bone Loss in Midlife Predicts Subsequent Fracture Independent of Starting Bone Mineral Density

CONTEXT

Bone mineral density (BMD) decreases rapidly during menopause transition (MT), and continues to decline in postmenopause.

OBJECTIVE

This work aims to examine whether faster BMD loss during the combined MT and early postmenopause is associated with incident fracture, independent of starting BMD, before the MT.

METHODS

The Study of Women's Health Across the Nation, a longitudinal cohort study, included 451 women, initially premenopausal or early perimenopausal, and those transitioned to postmenopause. Main outcome measures included time to first fracture after early postmenopause.

RESULTS

In Cox proportional hazards regression, adjusted for age, body mass index, race/ethnicity, study site, use of vitamin D and calcium supplements, and use of bone-detrimental or -beneficial medications, each SD decrement in lumbar spine (LS) BMD before MT was associated with a 78% increment in fracture hazard (P = .007). Each 1% per year faster decline in LS BMD was related to a 56% greater fracture hazard (P = .04). Rate of LS BMD decline predicted future fracture, independent of starting BMD. Women with a starting LS BMD below the sample median, and an LS BMD decline rate faster than the sample median had a 2.7-fold greater fracture hazard (P = .03). At the femoral neck, neither starting BMD nor rate of BMD decline was associated with fracture.

CONCLUSION

At the LS, starting BMD before the MT and rate of decline during the combined MT and early postmenopause are independent risk factors for fracture. Women with a below-median starting LS BMD and a faster-than-median LS BMD decline have the greatest fracture risk.

Logistic regression analysis on risk factors of augmented vertebra recompression after percutaneous vertebral augmentation

Objective

To explore the high-risk factors of augmented vertebra recompression after percutaneous vertebral augmentation (PVA) in the treatment of osteoporotic vertebral compression fracture (OVCF) and analyze the correlation between these factors and augmented vertebra recompression after PVA.

Methods

A retrospective analysis was conducted on 353 patients who received PVA for a single-segment osteoporotic vertebral compression fracture from January 2017 to December 2018 in our department according to the inclusion criteria. All cases meeting the inclusion and exclusion criteria were divided into two groups: 82 patients in the recompression group and 175 patients in the non-compression group. The following covariates were reviewed: age, gender, body mass index (BMI), injured vertebral segment, bone mineral density (BMD) during follow-up, intravertebral cleft (IVC) before operation, selection of surgical methods, unilateral or bilateral puncture, volume of bone cement injected, postoperative leakage of bone cement, distribution of bone cement, contact between the bone cement and the upper or lower endplates, and anterior height of injured vertebrae before operation, after surgery, and at the last follow-up. Univariate analysis was performed on these factors, and the statistically significant factors were substituted into the logistic regression model to analyze their correlation with the augmented vertebra recompression after PVA.

Results

A total of 257 patients from 353 patients were included in this study. The follow-up time was 12–24 months, with an average of 13.5 ± 0.9 months. All the operations were successfully completed, and the pain of patients was relieved obviously after PVA. Univariate analysis showed that in the early stage after PVA, the augmented vertebra recompression was correlated with BMD, surgical methods, volume of bone cement injected, preoperative IVC, contact between bone cement and the upper or lower endplates, and recovery of anterior column height. The difference was statistically significant (P < 0.05). Among them, multiple factors logistic regression elucidated that more injected cement (P < 0.001, OR = 0.558) and high BMD (P = 0.028, OR = 0.583) were negatively correlated with the augmented vertebra recompression after PVA, which meant protective factors (B < 0). Preoperative IVC (P < 0.001, OR = 3.252) and bone cement not in contact with upper or lower endplates (P = 0.006, OR = 2.504) were risk factors for the augmented vertebra recompression after PVA. The augmented vertebra recompression after PVP was significantly less than that of PKP (P = 0.007, OR = 0.337).

Conclusions

The augmented vertebra recompression after PVA is due to the interaction of various factors, such as surgical methods, volume of bone cement injected, osteoporosis, preoperative IVC, and whether the bone cement is in contact with the upper or lower endplates.

How I Do It: Managing Corticosteroid-Related Comorbidities in Severe Asthma

Oral corticosteroid (OCS) use in severe asthma remains all too common despite advances in asthma treatment. Use of OCS is associated with significant toxicity that can have a lasting adverse impact on a patient's overall health. Monoclonal antibodies have been developed that reduce both the rate of occurrence of OCS-treated exacerbations and the OCS requirements in patients with oral corticosteroid-dependent asthma. This article describes strategies to prevent and best manage endocrine complications associated with OCS use and provides guidance on OCS dose management after the introduction of steroid-sparing therapies. (1) We identify OCS-dependent patients and assess for comorbidities including bone health, glycemic control, and adrenal function; (2) we begin attempts at OCS dose optimization before or soon after introducing a steroid-sparing biologic therapy; (3) we taper OCS, using explicit criteria for asthma control; (4) we assess hypothalamic-pituitary-adrenal axis integrity once a physiologic dose of OCS is achieved to guide further the rate of OCS taper; and (5) we manage corticosteroid-related comorbidities as detailed in this article.

Bone Mineral Density of the 1/3 Radius Refines Osteoporosis Diagnosis, Correlates With Prevalent Fractures, and Enhances Fracture Risk Estimates

OBJECTIVE

To investigate the added value of 1/3 radius (1/3R) for the diagnosis of osteoporosis by spine and hip sites and its correlation with prevalent fractures and predicted fracture risk.

METHODS

Fracture Risk Assessment Tool (FRAX) scores for hip and major osteoporotic fractures (MOF) with/without trabecular bone score were considered proxy for fracture risk. The contribution of 1/3R to risk prediction was depicted via linear regression models with FRAX score as the dependent variable-first only with central and then with radius T-score as an additional covariate. Significance of change in the explained variance was compared by F-test.

RESULTS

The study included 1453 patients, 86% women, aged 66 ± 10 years. A total of 32% (n = 471) were osteoporotic by spine/hip and 8% (n = 115) by radius only, constituting a 24.4% increase in the number of subjects defined as osteoporotic (n = 586, 40%). Prior fracture prevalence was similar among patients with osteoporosis by spine/hip (17.4%) and radius only (19.1%) (P = .77). FRAX prediction by a regression model using spine/hip T-score yielded explained variance of 51.8% and 49.9% for MOF and 39.8% and 36.4% for hip (with/without trabecular bone score adjustment, respectively). The contribution of 1/3R was statistically significant (P < .001) and slightly increased the explained variance to 52.3% and 50.4% for MOF and 40.9% and 37.4% for hip, respectively.

CONCLUSION

Reclassification of BMD results according to radius measurements results in higher diagnostic output. Prior fractures were equally prevalent among patients with radius-only and classic-site osteoporosis. FRAX tool performance slightly improved by incorporating radius BMD. Whether this approach may lead to a better fracture prediction warrants further prospective evaluation.