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Niimi R, Kono T, Nishihara A, Hasegawa M, Matsumine A, Kono T, Sudo A. Analysis of daily teriparatide treatment for osteoporosis in men. Osteoporos Int 2015; 26:1303-9. [PMID: 25567777 DOI: 10.1007/s00198-014-3001-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 12/09/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED The percent and absolute lumbar spine and femoral neck bone mineral densities and absolute procollagen type I N-terminal propeptide (PINP) increases following a 20-μg/day teriparatide treatment for 12 months were similar in men and women regardless of sex differences. INTRODUCTION Several placebo-controlled studies have measured the effects of daily teriparatide in men and postmenopausal women with osteoporosis but none have directly compared the effects between these groups. We retrospectively compared the effects of daily teriparatide therapy in men and postmenopausal women with osteoporosis and investigated biochemical markers of bone turnover to detect possible sex differences. METHODS Patients (563; 75 men and 488 women) with osteoporosis were retrospectively investigated. All patients were administered with teriparatide at 20 μg/day for 12 months. The primary efficacy measure was changed in lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD) after 12 months of treatment. The change in serum levels of procollagen type I N-terminal propeptide (PINP) and urinary N-telopeptide (uNTX) excretion after 4, 8 and 12 months of treatment were also measured. RESULTS In men, the percent LS BMD significantly increased by 11.3 ± 9.9 % (mean ± standard deviation (SD)) and the FN BMD increased by 0.4 ± 6.4 % without a significant difference at 12 months. In postmenopausal women, the percent LS BMD significantly increased by 9.6 ± 8.1 % and the FN BMD significantly increased by 2.4 ± 7.8 % at 12 months. The percent and absolute BMD increases in LS and FN between men and women were similar. The absolute increases in PINP were similar in both groups at 4, 8 and 12 months. However, the absolute increases in uNTX were significantly lower in men than in women at 8 and 12 months. CONCLUSION Daily teriparatide treatment was as effective in men as in postmenopausal women regardless of sex differences.
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Affiliation(s)
- R Niimi
- Department of Orthopaedic Surgery, Tomidahama Hospital, 26-14, Tomidahamacho, Yokkaichi, Mie, 510-8008, Japan,
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302
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Krueger D, Libber J, Binkley N. Spine Trabecular Bone Score Precision, a Comparison Between GE Lunar Standard and High-Resolution Densitometers. J Clin Densitom 2015; 18:226-32. [PMID: 25659179 DOI: 10.1016/j.jocd.2014.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 11/14/2014] [Accepted: 11/18/2014] [Indexed: 10/24/2022]
Abstract
Trabecular bone score (TBS) is related to microarchitecture and fracture risk independently of bone mineral density (BMD) and clinical risk factors. Widespread clinical TBS use requires documentation of reproducibility and ideally comparability across scanners. This study evaluated TBS reproducibility and explored differences between Lunar Prodigy and iDXA densitometers. Reproducibility was assessed from replicate scans in 210 men and women participating in various dual-energy X-ray absorptiometry (DXA) precision assessments. iDXA-to-Prodigy comparability was evaluated using 155 participants from 3 study groups. L1-L4 BMD and TBS precision was similar on iDXA and Prodigy (BMD coefficient of variation = 1.9% and 1.5% and TBS coefficient of variation = 1.4% and 1.6%, respectively). Precision did not differ between men and women; however, between-technologist differences (p < 0.05) of similar magnitude were observed for both BMD and TBS. Prodigy-to-Prodigy TBS values were highly correlated (R(2) = 0.85 with bias of -0.010 TBS units). Agreement was less robust comparing Prodigy with iDXA instruments (TBS R(2): 0.72-0.81 with biases of 0.012-0.034 TBS units). In conclusion, TBS precision is comparable to that of BMD and does not differ between men and women. Additionally, in these cohorts, slight TBS differences were observed between iDXA and Prodigy scans. These data suggest a potential difference between densitometer models perhaps due to higher iDXA image resolution.
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Affiliation(s)
- Diane Krueger
- Osteoporosis Clinical Research Program, University of Wisconsin, Madison, WI, USA.
| | - Jessie Libber
- Osteoporosis Clinical Research Program, University of Wisconsin, Madison, WI, USA
| | - Neil Binkley
- Osteoporosis Clinical Research Program, University of Wisconsin, Madison, WI, USA
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303
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Mays S. Age-associated reduction in cortical bone in males, trends from the third century AD to the present day. Calcif Tissue Int 2015; 96:370-1. [PMID: 25673504 DOI: 10.1007/s00223-015-9958-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 01/21/2015] [Indexed: 11/28/2022]
Abstract
Osteoporosis is increasingly recognised as a health threat in the ageing male. Risk factors for osteoporosis appear to have increased through time. This study investigates the hypothesis that lifestyle changes (e.g. increasing sedentism, tobacco use) over the past 1,800 years have resulted in greater age-related reduction in cortical bone in males in more recent compared with earlier times in England. Skeletons (N = 215) from three English archaeological sites dating from the third to nineteenth century AD, together with comparison with a modern reference population, are used to investigate this hypothesis. Metacarpal cortical thickness is used as a measure of cortical bone status. Results of this cross-sectional study do not support the above hypothesis but instead suggest that patterns of age-related reduction in cortical bone in males have remained stable over an 1,800 year period.
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Affiliation(s)
- Simon Mays
- Analysis and Investigation Division, English Heritage, Fort Cumberland, Portsmouth, PO4 9LD, UK,
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304
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Di Monaco M, Castiglioni C, Di Monaco R, Tappero R. Prevalence and burden of vertebral fractures in older men and women with hip fracture: A cross-sectional study. Geriatr Gerontol Int 2015; 16:352-7. [DOI: 10.1111/ggi.12479] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Marco Di Monaco
- Osteoporosis Research Center; Division of Physical and Rehabilitation Medicine; Presidio Sanitario San Camillo; Fondazione Opera San Camillo; Torino Italy
| | - Carlotta Castiglioni
- Osteoporosis Research Center; Division of Physical and Rehabilitation Medicine; Presidio Sanitario San Camillo; Fondazione Opera San Camillo; Torino Italy
| | - Roberto Di Monaco
- Department of Culture, Politics, and Society; University; Torino Italy
| | - Rosa Tappero
- Osteoporosis Research Center; Division of Physical and Rehabilitation Medicine; Presidio Sanitario San Camillo; Fondazione Opera San Camillo; Torino Italy
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305
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Lunenfeld B, Mskhalaya G, Zitzmann M, Arver S, Kalinchenko S, Tishova Y, Morgentaler A. Recommendations on the diagnosis, treatment and monitoring of hypogonadism in men. Aging Male 2015; 18:5-15. [PMID: 25657080 PMCID: PMC4648196 DOI: 10.3109/13685538.2015.1004049] [Citation(s) in RCA: 205] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Accepted: 12/26/2014] [Indexed: 01/02/2023] Open
Abstract
Hypogonadism or Testosterone Deficiency (TD) in adult men as defined by low levels of serum testosterone accompanied by characteristic symptoms and/or signs as detailed further on can be found in long-recognized clinical entities such as Klinefelter syndrome, Kallmann syndrome, pituitary or testicular disorders, as well as in men with idiopathic, metabolic or iatrogenic conditions that result in testosterone deficiency. These recommendations do not encompass the full range of pathologies leading to hypogonadism (testosterone deficiency), but instead focus on the clinical spectrum of hypogonadism related to metabolic and idiopathic disorders that contribute to the majority of cases that occur in adult men.
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Affiliation(s)
- Bruno Lunenfeld
- Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
| | - George Mskhalaya
- Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
| | - Michael Zitzmann
- Centre for Reproductive Medicine and Andrology, University Clinics Muenster, Münster, Germany
| | - Stefan Arver
- Centre for Andrology and Sexual Medicine, Karolinska University Hospital and Karolinska Institutet Stockholm, Stockholm, Sweden
| | - Svetlana Kalinchenko
- Clinical Endocrinology, Peoples' Friendship University of Russia, Moscow, Russian Federation
| | - Yuliya Tishova
- Clinical Endocrinology, Peoples' Friendship University of Russia, Moscow, Russian Federation
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306
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Pop LC, Sukumar D, Tomaino K, Schlussel Y, Schneider SH, Gordon CL, Wang X, Shapses SA. Moderate weight loss in obese and overweight men preserves bone quality. Am J Clin Nutr 2015; 101:659-67. [PMID: 25733651 PMCID: PMC4340066 DOI: 10.3945/ajcn.114.088534] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Weight loss (WL) negatively affects bone mineral density (BMD) in older populations and has specifically been shown in women. OBJECTIVE In this prospective controlled trial, we examined variables of bone quality and endocrine changes after intentional WL in men. DESIGN Thirty-eight overweight and obese [mean ± SD body mass index (in kg/m²): 31.9 ± 4.4; age: 58 ± 6 y] men were recruited to either WL through caloric restriction or weight maintenance (WM) for 6 mo. RESULTS There was a -7.9 ± 4.4% and +0.2 ± 1.6% change in body weight in the WL and WM groups, respectively. There was a greater increase in femoral neck and total body BMD and bone mineral content (BMC) in the WM group than in the WL group (P-interaction effect < 0.05). In contrast, there was a trend for the tibia cortical thickness and area to decrease more in the WM group than in the WL group (P ≤ 0.08). There was a decrease in the periosteal circumference in both groups over time (P < 0.01) and no statistically significant changes in trabecular bone. Circulating total, free, and bioavailable estradiol decreased in the WL group compared with the WM group, and changes were different between groups (P < 0.05). Serum total and bioavailable testosterone increased in both groups (P < 0.01). Serum 25-hydroxyvitamin D increased to a similar extent in both groups (P < 0.05). CONCLUSIONS Moderate WL in overweight and obese men did not decrease BMD at any anatomical site or alter cortical and trabecular bone and geometry. Also, despite increased BMD at some sites when maintaining excess body weight, cortical bone showed a trend in the opposite direction.
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Affiliation(s)
- L Claudia Pop
- From the Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ (LCP, DS, KT, YS, and SAS); the Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (SHS and XW); and the Department of Radiology, McMaster University, Hamilton, Ontario, Canada (CLG)
| | - Deeptha Sukumar
- From the Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ (LCP, DS, KT, YS, and SAS); the Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (SHS and XW); and the Department of Radiology, McMaster University, Hamilton, Ontario, Canada (CLG)
| | - Katherine Tomaino
- From the Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ (LCP, DS, KT, YS, and SAS); the Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (SHS and XW); and the Department of Radiology, McMaster University, Hamilton, Ontario, Canada (CLG)
| | - Yvette Schlussel
- From the Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ (LCP, DS, KT, YS, and SAS); the Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (SHS and XW); and the Department of Radiology, McMaster University, Hamilton, Ontario, Canada (CLG)
| | - Stephen H Schneider
- From the Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ (LCP, DS, KT, YS, and SAS); the Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (SHS and XW); and the Department of Radiology, McMaster University, Hamilton, Ontario, Canada (CLG)
| | - Chris L Gordon
- From the Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ (LCP, DS, KT, YS, and SAS); the Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (SHS and XW); and the Department of Radiology, McMaster University, Hamilton, Ontario, Canada (CLG)
| | - Xiangbing Wang
- From the Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ (LCP, DS, KT, YS, and SAS); the Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (SHS and XW); and the Department of Radiology, McMaster University, Hamilton, Ontario, Canada (CLG)
| | - Sue A Shapses
- From the Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ (LCP, DS, KT, YS, and SAS); the Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (SHS and XW); and the Department of Radiology, McMaster University, Hamilton, Ontario, Canada (CLG)
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307
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LaFleur J, Steenhoek CL, Horne J, Meier J, Nebeker JR, Mambourg S, Swislocki A, Carmichael J. Comparing fracture absolute risk assessment (FARA) tools: an osteoporosis clinical informatics tool to improve identification and care of men at high risk of first fracture. Ann Pharmacother 2015; 49:506-14. [PMID: 25712443 DOI: 10.1177/1060028015572819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Fracture absolute risk assessment (FARA) is recommended for guiding osteoporosis treatment decisions in males. The best strategy for applying FARA in the clinic setting is not known. OBJECTIVES We compared 2 FARA tools for use with electronic health records (EHRs) to determine which would more accurately identify patients known to be high risk for fracture. Tools evaluated were an adaptation of the World Health Organization's Fracture Risk Assessment Tool used with electronic data (eFRAX) and the Veterans Affairs (VA)-based tool, VA-FARA. METHODS We compared accuracies of VA-FARA and eFRAX for correctly classifying male veterans who fractured and who were seen in the VA's Sierra Pacific Network in 2002-2013. We then matched those cases to nonfracture controls to compare odds of fracture in patients classified as high risk by either tool. RESULTS Among 8740 patients, the mean (SD) age was 67.0 (11.1) years. Based on risk factors present in the EHR, VA-FARA correctly classified 40.1% of fracture patients as high risk (33.0% and 34.6% for hip and any major fracture, respectively); eFRAX classified 17.4% correctly (17.4% for hip and 0.2% for any major fracture). Compared with non-high-risk patients, those classified as high risk by VA-FARA were 35% more likely to fracture (95% CI = 23%-47%; P < 0.01) compared with 17% for eFRAX (95% CI = 5%-32%; P < 0.01). CONCLUSIONS VA-FARA is more predictive of first fracture than eFRAX using EHR data. Decision support tools based on VA-FARA may improve early identification and care of men at risk.
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Affiliation(s)
- Joanne LaFleur
- Pharmacotherapy Outcomes Research Center, Salt Lake City, UT, USA George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Chandra L Steenhoek
- Department of Veterans Affairs Sierra Pacific Network (VISN 21), Vallejo, CA, USA
| | - Julie Horne
- James H. Quillen Department of Veterans Affairs Medical Center, Mountain Home, TN, USA
| | - Joy Meier
- Department of Veterans Affairs Sierra Pacific Network (VISN 21), Vallejo, CA, USA
| | - Jonathan R Nebeker
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | | | - Arthur Swislocki
- Department of Veterans Affairs Northern California Health Care System, VA Martinez Outpatient Clinic, Martinez, CA, USA University of California Davis School of Medicine, Sacramento, CA, USA
| | - Jannet Carmichael
- Department of Veterans Affairs Sierra Pacific Network (VISN 21), Vallejo, CA, USA
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308
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Grossmann M, Anawalt BD, Wu FCW. Clinical practice patterns in the assessment and management of low testosterone in men: an international survey of endocrinologists. Clin Endocrinol (Oxf) 2015; 82:234-41. [PMID: 25154540 DOI: 10.1111/cen.12594] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 07/15/2014] [Accepted: 08/18/2014] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To document current practices in the approach to low testosterone in older men. Given that recommendations are based on low-level evidence, we hypothesized that there would be a wide variability in clinical practice patterns. DESIGN Members of all major endocrine and andrological societies were invited to participate in a Web-based survey of the diagnostic work-up and management of a hypothetical index case of a 61-year old overweight man presenting with symptoms suggestive of androgen deficiency, without evidence of hypothalamic-pituitary-gonadal (HPT) axis disease. RESULTS Nine hundred and forty-three respondents (91·2% adult endocrinologists) from Northern America (63·7%), Europe (12·7%), Oceania (8·2%), Latin America and Caribbean (7·6%), and the Middle East, Asia, or Africa (7·8%) completed the survey. Response rates among participating societies ranged from 4·1-20·0%. There was a wide variability in clinical practice patterns, especially regarding biochemical diagnosis of androgen deficiency, exclusion of HPT axis pathology, and monitoring for prostate cancer. In a man with suggestive symptoms, 42·4% of participants would offer testosterone treatment below a serum total testosterone of 10·4 nmol/l (300 ng/dl). A total of 46·0% of participants were, over the last five years, 'less inclined' to prescribe testosterone to men with nonspecific symptoms and borderline testosterone levels, compared to 'no change' (29·3%) or 'more inclined' (24·7%), P < 0·001. CONCLUSIONS This large-scale international survey shows a wide variability in the management of lowered testosterone in older men, with deviations from current clinical practice guidelines, and a temporal trend towards increasing reluctance to prescribe testosterone to men without classical hypogonadism. These findings highlight the need for better evidence to guide clinicians regarding testosterone therapy.
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Affiliation(s)
- Mathis Grossmann
- Department of Medicine Austin Health, University of Melbourne, Heidelberg, Vic, Australia
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309
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Teriparatide treatment of osteoporosis in an HIV-infected man: a case report and literature review. AIDS 2015; 29:245-6. [PMID: 25532609 DOI: 10.1097/qad.0000000000000529] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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310
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Willson T, Nelson SD, Newbold J, Nelson RE, LaFleur J. The clinical epidemiology of male osteoporosis: a review of the recent literature. Clin Epidemiol 2015; 7:65-76. [PMID: 25657593 PMCID: PMC4295898 DOI: 10.2147/clep.s40966] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Osteoporosis, a musculoskeletal disease characterized by decreased bone mineral density (BMD) and an increased risk of fragility fractures, is now recognized as an important public health problem in men. Osteoporotic fractures, particularly of the hip, result in significant morbidity and mortality in men and lead to considerable societal costs. Many national and international organizations now address screening and treatment for men in their osteoporosis clinical guidelines. However, male osteoporosis remains largely underdiagnosed and undertreated. The objective of this paper is to provide an overview of recent findings in male osteoporosis, including pathophysiology, epidemiology, and incidence and burden of fracture, and discuss current knowledge about the evaluation and treatment of osteoporosis in males. In particular, clinical practice guidelines, fracture risk assessment, and evidence of treatment effectiveness in men are addressed.
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Affiliation(s)
- Tina Willson
- University of Utah College of Pharmacy, Salt Lake City, UT, USA
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Scott D Nelson
- University of Utah College of Pharmacy, Salt Lake City, UT, USA
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
| | | | - Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Joanne LaFleur
- University of Utah College of Pharmacy, Salt Lake City, UT, USA
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
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311
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Abstract
All forms of hypogonadism - primary, secondary and late-onset - require testosterone substitution. The indication is given when the patient presents with symptoms of androgen deficiency and the serum testosterone levels are below normal. Several testosterone preparations and modes of application are available of which those producing physiologic serum levels should be preferred e.g. preferentially transdermal gels and long-acting intramuscular testosterone undecanoate. Testosterone substitution must be monitored at regular intervals, best at 3, 6 and 12 months after initiation and then annually. Parameters for surveillance include well-being, libido and sexual activity, measurement of serum testosterone levels, haemoglobin and haematocrit, PSA and digital rectal examination, and, biannually, bone mineral density. Testosterone has positive effects on comorbidities such as obesity, metabolic syndrome, diabetes type II, cardiovascular diseases and osteoporosis.
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Affiliation(s)
- Eberhard Nieschlag
- Centre of Reproductive Medicine and Andrology, University Hospitals, Münster, Germany; Center of Excellence in Genomic Medicine Research, King Abdulaziz University, Jeddah, Saudi Arabia.
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312
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Abstract
PURPOSE OF REVIEW The aim of treatment in patients at high risk for fractures is to reduce the risk of a first or a subsequent fracture. New data are available on the antifracture effects and side-effects of antiresorptive and osteoanabolic drugs, and new emerging therapies with new modes of action are on the horizon. RECENT FINDINGS Calcium and vitamin D intake should be sufficient, but not too high. Vertebral, nonvertebral (including hip fracture) prevention with antiresorptive drugs such as bisphosphonates (alendronate, risedronate and zoledronic acid) and denosumab exceeds the risk of rare side-effects such as atypical femur fracture and osteonecrosis of the jaw. Teriparatide is an osteoanabolic drug that improves quality of life in severe osteoporosis. Strontium ranelate decreases dynamic parameters of bone formation during the first year of treatment, and could increase the risk of cardiovascular events in high-risk patients. Initiation of and adherence to fracture prevention drugs are still low. New potential developments in antiresorptive drugs include odanacatib, a selective inhibitor of cathepsin K, and, in osteoanabolic drugs, monoclonal antibodies against sclerostin. SUMMARY These recent data indicate that fracture prevention with antiresorptives and teriparatide is effective with a reasonable safety profile. Odanacatib and antisclerostin are promising new drugs with new mechanisms of action, as they are able to disconnect the normal coupling between bone resorption and bone formation.
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313
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Gioia A, Ceccoli L, Ronconi V, Turchi F, Marcheggiani M, Boscaro M, Giacchetti G, Balercia G. Vitamin D levels and bone mineral density: are LH levels involved in the pathogenesis of bone impairment in hypogonadal men? J Endocrinol Invest 2014; 37:1225-31. [PMID: 25323435 DOI: 10.1007/s40618-014-0187-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 09/22/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Osteoporosis is a major public health problem also in men and it recognizes hypogonadism as a major cause. AIMS To investigate the possible pathogenetic mechanisms on bone impairment in male hypogonadism and on its improvement in response to testosterone replacement treatment (TRT). METHODS We retrospectively investigated the hormonal profile and bone mineral density (BMD), evaluated by DXA, in 17 middle-aged hypogonadal men treated for at least 5 years with TRT, compared with 21 recently diagnosed untreated hypogonadal males and 18 age- and BMI-matched healthy subjects. RESULTS No significant differences in clinical, biochemical and densitometric parameters were found among the three groups, with the exception of 25-OH vitamin D levels that were significantly higher in healthy subjects compared with hypogonadal patients. Untreated patients affected by central hypogonadism, despite similar hormonal levels, displayed significantly lower BMD and decreased LH and 25-OH vitamin D levels, compared with patients with primary hypogonadism. Among the treated patients, BMD parameters were similar regardless of the formulation of TRT. CONCLUSIONS A recent history of central hypogonadism, compared with primary hypogonadism, appears to adversely affect bone health independently of gonadal steroids levels. This could be due to lower LH levels and consequent reduction of vitamin D 25-hydroxylation in the testis.
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Affiliation(s)
- A Gioia
- Division of Endocrinology, Polytechnic University of Marche, Ospedali Riuniti Umberto I-GM Lancisi-G Salesi, Ancona, Italy
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314
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Gaspar AP, Brandão CMA, Lazaretti-Castro M. Bone mass and hormone analysis in patients with spinal cord injury: evidence for a gonadal axis disruption. J Clin Endocrinol Metab 2014; 99:4649-55. [PMID: 25222754 DOI: 10.1210/jc.2014-2165] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTEXT Bone loss is a constant finding in patients with spinal cord injury (SCI). OBJECTIVE We sought to evaluate potential modifiable factors that could lead to bone loss in complete motor paraplegia by examining gonadal axis hormones, vitamin D status, and bone markers. DESIGN This is a cross sectional. SETTING It includes SCI Outpatient. PATIENTS AND OTHER PARTICIPANTS Twenty-nine chronic male patients with SCI were compared with 17 age-matched, able-bodied men. MAIN OUTCOME MEASURE The bone mineral density (BMD) of lower limbs and lumbar spine were measured using dual x-ray absorptiometry. Parathormone, 25-hydroxyvitamin D [25(OH)D], collagen type I C-terminal telopeptide (CTX), and sexual hormone were measured. RESULTS Patients with SCI had lower BMD at the inferior limbs sites. CTX showed an inverse relationship with the time since injury. Patients had lower free T levels (SCI, 12.00 ± 2.91 vs controls, 19.51 ± 5.72; P ≤ .001), and the majority (72%) had normal/low levels of gonadotropins. Low T, however, was not related to low bone mass in patients with SCI. In the controls, the 25(OH)D level was positively correlated with the T and with the lumbar spine BMD, but these correlations were not observed in the SCI. CONCLUSIONS Impairment of testicular function after SCI was indicated by the low levels of T and the loss of correlation between T and 25(OH)D levels; this correlation was present in the able-bodied controls. Inappropriate levels of gonadotropins were identified in most patients, featuring a hypogonadotropic hypogonadism and suggesting a disruption of the pituitary-gonadal axis. T concentrations might not be an effective target for bone loss therapy.
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Affiliation(s)
- Alexandra Passos Gaspar
- Division of Endocrinology (A.P.G., C.M.A.B., M.L.-C.), Universidade Federal de São Paulo, São Paulo 04021-001, Brazil; and Associação de Assistência à Criança Deficiente (A.P.G.), São Paulo 04027-000, Brazil
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315
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Abstract
One in three osteoporotic fractures occur in men and the consequences of a fracture in men tend to be more severe than in women. Still, only a small minority of men with high risk of fracture are detected and treated. Although there are gender differences in the pathophysiology of osteoporosis, such as in the pattern of bone loss, similarities predominate, which is also the case for clinical risk factors. It seems appropriate to consider treatment for men and women with a similar 10 year fracture risk. Drugs now approved for treatment of osteoporosis in men include the anti-resorptive bisphosphonates alendronate, residronate and zoledronic acid, the anti-resorptive drug denosumab, the bone-forming agent teriparatide, and (not in the US) strontium ranelate with mild opposite effects on resorption and formation. Although the evidence level for efficacy and safety of these drugs in men is still relatively limited, available data indicate that treatment effects in men are very similar to what has been observed in the treatment of postmenopausal osteoporosis. Denosumab is also approved for treatment in men receiving androgen deprivation therapy for non-metastatic prostate cancer; bisphosphonates and teriparatide are also available to clinicians for treatment of glucocorticoid-induced osteoporosis in men. Testosterone treatment may be indicated in men with documented symptomatic hypogonadism, but osteoporosis is neither a sufficient nor a specific indication for testosterone treatment. New compounds with well advanced clinical development include odanacatib, a selective inhibitor of the cysteine protease cathepsin-K, and romosozumab, a monoclonal antibody against sclerostin.
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Affiliation(s)
- Jean-Marc Kaufman
- Department of Endocrinology and Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium.
| | - Bruno Lapauw
- Department of Endocrinology and Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - Stefan Goemaere
- Department of Endocrinology and Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
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316
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Abstract
Osteoporosis becomes common with aging in both sexes, but is often ignored in men. The 2013 International Society for Clinical Densitometry consensus conference endorsed a Caucasian female referent database for T-score calculation in men. This recommendation has generated controversy and concern. Accumulating data indicate that at the same DXA-measured body mineral density (BMD) (g/cm(2)), men and women are at approximately the same fracture risk. With this point in mind, using the same database to derive the T-score in men and women is reasonable. As a result, a greater proportion of men who sustain a fragility fracture will have T-scores that are higher than they would if a male database were used; in fact, many men will fracture at T-scores that are "normal." This highlights the importance of diagnosing osteoporosis not just by T-score, but also by the presence of fragility fracture and/or by estimations of fracture risk as generated by tools such as the FRAX calculator. The practical consequences of this change in densitometric definition of osteoporosis in men should be monitored, including the proportion of men at risk identified and treated as well as defining the response to treatment in those assessed by this more comprehensive approach.
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Affiliation(s)
- Neil Binkley
- University of Wisconsin Osteoporosis Clinical Research Program, 2870 University Avenue, Suite 100, Madison, WI 53705. Phone: 608.265.6410 Fax: 608.265.6409
| | - Robert Adler
- Endocrinology Section, McGuire Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, Richmond, VA, 23249. Phone 804 675 5424; Fax 804 675 5425
| | - John P. Bilezikian
- College of Physicians and Surgeons, Department of Medicine, Division of Endocrinology, 630 W. 168 Street, New York, NY 10032 Phone: 212.305.6238; Fax: 212.305.6486
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317
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Vanderschueren D, Laurent MR, Claessens F, Gielen E, Lagerquist MK, Vandenput L, Börjesson AE, Ohlsson C. Sex steroid actions in male bone. Endocr Rev 2014; 35:906-60. [PMID: 25202834 PMCID: PMC4234776 DOI: 10.1210/er.2014-1024] [Citation(s) in RCA: 184] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Sex steroids are chief regulators of gender differences in the skeleton, and male gender is one of the strongest protective factors against osteoporotic fractures. This advantage in bone strength relies mainly on greater cortical bone expansion during pubertal peak bone mass acquisition and superior skeletal maintenance during aging. During both these phases, estrogens acting via estrogen receptor-α in osteoblast lineage cells are crucial for male cortical and trabecular bone, as evident from conditional genetic mouse models, epidemiological studies, rare genetic conditions, genome-wide meta-analyses, and recent interventional trials. Genetic mouse models have also demonstrated a direct role for androgens independent of aromatization on trabecular bone via the androgen receptor in osteoblasts and osteocytes, although the target cell for their key effects on periosteal bone formation remains elusive. Low serum estradiol predicts incident fractures, but the highest risk occurs in men with additionally low T and high SHBG. Still, the possible clinical utility of serum sex steroids for fracture prediction is unknown. It is likely that sex steroid actions on male bone metabolism rely also on extraskeletal mechanisms and cross talk with other signaling pathways. We propose that estrogens influence fracture risk in aging men via direct effects on bone, whereas androgens exert an additional antifracture effect mainly via extraskeletal parameters such as muscle mass and propensity to fall. Given the demographic trends of increased longevity and consequent rise of osteoporosis, an increased understanding of how sex steroids influence male bone health remains a high research priority.
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Affiliation(s)
- Dirk Vanderschueren
- Clinical and Experimental Endocrinology (D.V.) and Gerontology and Geriatrics (M.R.L., E.G.), Department of Clinical and Experimental Medicine; Laboratory of Molecular Endocrinology, Department of Cellular and Molecular Medicine (M.R.L., F.C.); and Centre for Metabolic Bone Diseases (D.V., M.R.L., E.G.), KU Leuven, B-3000 Leuven, Belgium; and Center for Bone and Arthritis Research (M.K.L., L.V., A.E.B., C.O.), Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 413 45 Gothenburg, Sweden
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318
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Wells AJ, McLaughlin P, Simmonds JV, Prouse PJ, Prelevic G, Gill S, Chowdary P. A case-control study assessing bone mineral density in severe haemophilia A in the UK. Haemophilia 2014; 21:109-15. [PMID: 25382849 DOI: 10.1111/hae.12565] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2014] [Indexed: 11/27/2022]
Abstract
It has been shown that bone mineral density (BMD) may be lower in patients with haemophilia (PWH). A comparison to control subjects is required to thoroughly assess current BMD in PWH in the UK. The objective of this study was to test the hypothesis that BMD is lower in PWH than in controls, and in patients with more severely affected joints or lower activity levels. In this case-control study, 37 patients with severe haemophilia A were recruited from two haemophilia centres in the UK. A group of 37 age, gender and ethnicity-matched control participants were recruited. All participants had a bone density scan, a musculoskeletal assessment, a blood test for vitamin D and completed a functional activity questionnaire. Of the case group, 5% had osteoporosis and 24% had BMD lower than expected for age. No control participants had osteoporosis, 3% had osteopenia and 14% had BMD lower than expected for age. Ninety one per cent of case participants and 92% of control participants had reduced 25(OH)D levels. Case participants had significantly lower BMD than control participants, and case participants with more severely affected joints, lower activity levels, HIV, history of hepatitis C or lower BMI had significantly lower BMD. Patients with severe haemophilia have a higher risk of low BMD than men without haemophilia. Patients with more severely affected joints and lower activity levels have lower BMD. It remains unclear whether patients with low BMD reached adequate peak bone mass. Low vitamin D may be present in the majority of PWH.
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Affiliation(s)
- A J Wells
- Haemophilia, Haemostasis & Thrombosis Centre, Basingstoke & North Hampshire Hospital, Basingstoke, UK; University of Hertfordshire, Hatfield, UK
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319
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320
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321
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Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, Lindsay R. Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int 2014; 25:2359-81. [PMID: 25182228 PMCID: PMC4176573 DOI: 10.1007/s00198-014-2794-2] [Citation(s) in RCA: 1971] [Impact Index Per Article: 197.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 06/24/2014] [Indexed: 02/07/2023]
Abstract
The Clinician's Guide to Prevention and Treatment of Osteoporosis was developed by an expert committee of the National Osteoporosis Foundation (NOF) in collaboration with a multispecialty council of medical experts in the field of bone health convened by NOF. Readers are urged to consult current prescribing information on any drug, device, or procedure discussed in this publication.
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Affiliation(s)
- F Cosman
- Helen Hayes Hospital, West Haverstraw, NY, USA,
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322
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Genetic polymorphisms in the mevalonate pathway affect the therapeutic response to alendronate treatment in postmenopausal Chinese women with low bone mineral density. THE PHARMACOGENOMICS JOURNAL 2014; 15:158-64. [DOI: 10.1038/tpj.2014.52] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 06/15/2014] [Accepted: 08/13/2014] [Indexed: 11/08/2022]
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323
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Liu M, Zhang Y, Cheng X, Lu Y, Li N, Gong Y, Pei Y, Li C. The effect of age on the changes in bone mineral density and osteoporosis detection rates in Han Chinese men over the age of 50. Aging Male 2014; 17:166-73. [PMID: 25027466 DOI: 10.3109/13685538.2014.940308] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To examine the relationship between age and BMD at different skeletal sites and osteoporosis (OP) detection rates in Han Chinese men over 50 years and to assess the diagnostic value of the OSTA. METHODS A retrospective analysis of 1488 men over 50 was carried out and group comparisons were made. RESULTS BMDs at total hip and femoral neck decreased with age (p < 0.01) and were negatively correlated with age by liner correlation analysis (r = -0.36, -0.30; p all <0.05). The detection rates of OP and osteopenia were 10.08% and 43.21% respectively, which increased with age, and significantly higher among over 70 years old than under 70 individuals (47.75% versus 35.56%; 14.88% versus 1.99%; p all <0.01). The detection rate at the femoral neck was similar to the overall detection rate. Sensitivities of OSTA index at a cutoff value of -1 and -4 were 87.33% and 52.0% respectively, and the specificities were 56.20% and 87.59%. CONCLUSION BMDs at femoral neck and total hip decrease with age. Detection rates of OP increase with age. Bilateral femoral neck BMD measurement can improve detection rates of OP. OSTA is a useful screening tool for OP in Han Chinese men over 50 years.
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Affiliation(s)
- Minyan Liu
- Department of Geriatric Endocrinology and
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324
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Abstract
OBJECTIVE Lead exposure linked to osteoporosis in women. However, there is no direct evidence whether lead exposure has effects on bone metabolism in middle-aged male subjects. Therefore, the present study investigated the relationship between bone mineral densitometry measurements, bone markers, endocrine hormones and blood lead levels. MATERIAL AND METHODS The present study included lead exposure patients (n: 30) and control subjects (n: 32). We recorded information on patient demographics and risk factors of osteoporosis. Blood lead levels were evaluated using Varian AA 240Z atomic absorption spectrophotometry. Bone mineral density measurements were measured using dual-energy X-ray absorptiometry. RESULTS Each lumbar T and Z scores in the lead exposure group were lower than the control group. There were no significant differences in femur neck and femur total T and Z scores between two groups. Blood lead levels were also negatively correlated with lumbar 2-4 T score, total lumbar T score, lumbar 2-4 Z score and total lumbar Z score. Urinary hydroxyproline and urinary deoxypyridinoline levels in the lead exposure group were significantly higher compared to controls. Blood lead levels were strong, positively correlated with urinary deoxypyridinoline. Endocrine hormone levels and 1,25-dihydroxy-vitamin D3 levels were comparable between lead exposure and control group. CONCLUSION Lead exposure in male workers is an important factor for deterioration in bone mineral density. We should be screening blood lead levels and history of lead exposure in male osteoporosis.
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Affiliation(s)
- Ayla Akbal
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Çanakkale Onsekiz Mart University , Çanakkale , Turkey and
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325
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León Vázquez F, Herrero Hernández S, Cuerpo Triguero C, Andrés Prado MJ, Cabello Ballesteros L. Prescription of alendronate and risedronate in men: off-label use in a health area. ACTA ACUST UNITED AC 2014; 11:64-7. [PMID: 25107345 DOI: 10.1016/j.reuma.2014.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 05/14/2014] [Accepted: 05/23/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Alendronate and risedronate are both effective and safe treatments for osteoporosis in men, but only risedronate has this indication in its data-sheet. We compared their use by gender. PATIENT AND METHODS Retrospective descriptive study of prescriptions of risedronate and alendronate in 2012 in primary care in the northwest area of the Community of Madrid. We compared patients and defined daily doses (DDD) dispensed by gender. RESULTS 14.857 patients used 1.847.370 DDD of alendronate or risedronate, 1.145 (7.7%) patients were men. In women alendronate was most prescribed (55% vs. 45%) than risedronate. Risedronate was preferred in men, 47.6% vs. 52.4%, resulting in a statistically significant difference (P<.001). CONCLUSIONS Risedronate is preferred to alendronate in men, which is often used off-label, despite the existence of alternatives.
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Affiliation(s)
- Fernando León Vázquez
- Centro de Salud Universitario San Juan de la Cruz, Pozuelo de Alarcón, Madrid, España.
| | - Silvia Herrero Hernández
- Servicio de Farmacia, Dirección Asistencial Noroeste, Gerencia de Atención Primaria, Servicio Madrileño de Salud, Majadahonda, Madrid, España
| | | | - M José Andrés Prado
- Unidad Docente Multidisciplinar de Atención Familiar y Comunitaria, Dirección Asistencial Noroeste, Gerencia de Atención Primaria, Servicio Madrileño de Salud, Majadahonda, Madrid, España
| | - Luisa Cabello Ballesteros
- Unidad Docente Multidisciplinar de Atención Familiar y Comunitaria, Dirección Asistencial Noroeste, Gerencia de Atención Primaria, Servicio Madrileño de Salud, Majadahonda, Madrid, España
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326
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Allan CA, Collins VR, Frydenberg M, McLachlan RI, Matthiesson KL. Androgen deprivation therapy complications. Endocr Relat Cancer 2014; 21:T119-29. [PMID: 24872511 DOI: 10.1530/erc-13-0467] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Androgen deprivation therapy (ADT) is increasingly used to treat advanced prostate cancer and is also utilised as adjuvant or neo-adjuvant treatment for high-risk disease. The resulting suppression of endogenous testosterone production has deleterious effects on quality of life, including hot flushes, reduced mood and cognition and diminished sexual function. Cross-sectional and longitudinal studies show that ADT has adverse bone and cardio-metabolic effects. The rate of bone loss is accelerated, increasing the risk of osteoporosis and subsequent fracture. Fat mass is increased and lean mass reduced, and adverse effects on lipid levels and insulin resistance are observed, the latter increasing the risk of developing type 2 diabetes. ADT also appears to increase the risk of incident cardiovascular events, although whether it increases cardiovascular mortality is not certain from the observational evidence published to date. Until high-quality evidence is available to guide management, it is reasonable to consider men undergoing ADT to be at a higher risk of psychosexual dysfunction, osteoporotic fracture, diabetes and cardiovascular disease, especially when treated for extended periods of time and therefore subjected to profound and prolonged hypoandrogenism. Health professionals caring for men undergoing treatment for prostate cancer should be aware of the potential risks of ADT and ensure appropriate monitoring and clinical management.
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Affiliation(s)
- Carolyn A Allan
- MIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, AustraliaMIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, AustraliaMIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, AustraliaMIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, Australia
| | - Veronica R Collins
- MIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, Australia
| | - Mark Frydenberg
- MIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, AustraliaMIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, Australia
| | - Robert I McLachlan
- MIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, AustraliaMIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, AustraliaMIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, AustraliaMIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, Australia
| | - Kati L Matthiesson
- MIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, AustraliaMIMR-PHI Institute of Medical Research27-31 Wright Street, Clayton, Victoria 3168, AustraliaAndrology AustraliaSchool of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, AustraliaDepartment of EndocrinologyMonash Health, Melbourne, Victoria, AustraliaDepartments of Obstetrics and GynaecologySurgeryMonash University, Clayton, Victoria, AustraliaDepartment of UrologyMedical ProgramMonash Health, Melbourne, Victoria, Australia
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327
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Cheung AS, Baqar S, Sia R, Hoermann R, Iuliano-Burns S, Vu TDT, Chiang C, Hamilton EJ, Gianatti E, Seeman E, Zajac JD, Grossmann M. Testosterone levels increase in association with recovery from acute fracture in men. Osteoporos Int 2014; 25:2027-33. [PMID: 24803329 DOI: 10.1007/s00198-014-2727-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 04/17/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED In this longitudinal case-control study, acute fracture was associated with low serum testosterone, which was transient in 43% of men. While assessment of gonadal status is part of the assessment of bone fragility, measurement of testosterone in the early period after fracture may overestimate the prevalence of androgen deficiency. INTRODUCTION Measurement of circulating testosterone is recommended in the evaluation of bone fragility in men. Since acute illness can transiently decrease circulating testosterone, we quantified the association of acute fracture and serum testosterone levels. METHODS A case-control study was conducted involving 240 men with a radiologically confirmed minimal trauma fracture presenting to a tertiary referral hospital and 89 age-matched men without a history of minimal trauma fracture serving as controls. Follow-up testosterone levels 6 months after baseline were available for 98 cases and 27 controls. Results were expressed as the median and interquartile (IQR) range. RESULTS Compared to controls, cases had lower total testosterone [TT, 7.2 (3.5, 10.8) vs 13.6 (10.9, 17.1) nmol/L, p < 0.001]. The 143 cases treated as inpatients had lower testosterone levels than the 97 cases treated as outpatients [TT 4.7 (2.3, 8.1) vs 10.3 (7.5, 12.7) nmol/L, p < 0.001]. Group differences in calculated free testosterone (cFT) were comparable to the group differences in TT. At follow-up, in 98 cases, median TT increased from 6.5 nmol/L (3.2, 8.5) to 9.6 nmol/L (6.9, 12.0) p < 0.0001, and SHBG remained unchanged. Of cases with low testosterone, 43% with TT <10 nmol/L and/or cFT <230 pmol/L at presentation were reclassified as androgen sufficient at follow-up. TT was unchanged in the controls. CONCLUSIONS Low testosterone levels in men presenting with an acute fracture may, at least in part, be due to an acute, fracture-associated, stress response. To avoid over diagnosis, evaluation for testosterone deficiency should be deferred until recovery from the acute event.
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Affiliation(s)
- A S Cheung
- Department of Endocrinology, Austin Health, The University of Melbourne, Heidelberg, Victoria, 3084, Australia
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328
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Ackman JM, Lata PF, Schuna AA, Elliott ME. Bone health evaluation in a veteran population: a need for the Fracture Risk Assessment Tool (FRAX). Ann Pharmacother 2014; 48:1288-93. [PMID: 24994725 DOI: 10.1177/1060028014542149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Approximately 2 million men in the United States have osteoporosis, but men are seldom evaluated or treated to prevent fracture. In the expanding veteran population, the fracture risk assessment tool, FRAX, could help reduce fracture risk. However, it is unknown how many veterans would meet the FRAX treatment threshold. OBJECTIVE To determine the proportion of untreated veterans who should be considered for osteoporosis treatment according to the Fracture Risk Assessment Tool (FRAX) among a randomly selected sample of older veterans receiving care at one Veterans Hospital and to determine the proportion of veterans in the sample who had received treatment. METHODS A retrospective review of 150 randomly selected charts from male veterans at least 70 years of age and female veterans at least 65 years of age receiving primary care at the William S. Middleton Memorial Veterans Hospital, Madison, WI, between January 1, 2007, and October 1, 2010. This study focused on men, but women were included per institutional review board policy. RESULTS Charts from 147 men and 3 women were reviewed; 25 men had received osteoporosis treatment. Of 122 untreated men, 74 (61%) met FRAX treatment criteria, including 14 who had fractured. Although bone density testing is recommended by the National Osteoporosis Foundation for men at least 70 years old, only 21 (17%) untreated men had been tested. CONCLUSIONS Most veterans who met FRAX criteria were not treated, including some who had had fractures. The VA should consider recommending FRAX to identify veterans at high risk for fracture.
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Affiliation(s)
| | - Paul F Lata
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Arthur A Schuna
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA University of Wisconsin School of Pharmacy, Madison, WI, USA
| | - Mary E Elliott
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA University of Wisconsin School of Pharmacy, Madison, WI, USA
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329
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Ensrud KE, Taylor BC, Peters KW, Gourlay ML, Donaldson MG, Leslie WD, Blackwell TL, Fink HA, Orwoll ES, Schousboe J. Implications of expanding indications for drug treatment to prevent fracture in older men in United States: cross sectional and longitudinal analysis of prospective cohort study. BMJ 2014; 349:g4120. [PMID: 24994809 PMCID: PMC4080830 DOI: 10.1136/bmj.g4120] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2014] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To quantify incremental effects of applying different criteria to identify men who are candidates for drug treatment to prevent fracture and to examine the extent to which fracture probabilities vary across distinct categories of men defined by these criteria. DESIGN Cross sectional and longitudinal analysis of a prospective cohort study. SETTING Multicenter Osteoporotic Fractures in Men (MrOS) study in the United States. PARTICIPANTS 5880 untreated community dwelling men aged 65 years or over classified into four distinct groups: osteoporosis by World Health Organization criteria alone; osteoporosis by National Osteoporosis Foundation (NOF) but not WHO criteria; no osteoporosis but at high fracture risk (at or above NOF derived FRAX intervention thresholds recommended for US); and no osteoporosis and at low fracture risk (below NOF derived FRAX intervention thresholds recommended for US). MAIN OUTCOME MEASURES Proportion of men identified for drug treatment; predicted 10 year probabilities of hip and major osteoporotic fracture calculated using FRAX algorithm with femoral neck bone mineral density; observed 10 year probabilities for confirmed incident hip and major osteoporotic (hip, clinical vertebral, wrist, or humerus) fracture events calculated using cumulative incidence estimation, accounting for competing risk of mortality. RESULTS 130 (2.2%) men were identified as having osteoporosis by using the WHO definition, and an additional 422 were identified by applying the NOF definition (total osteoporosis prevalence 9.4%). Application of NOF derived FRAX intervention thresholds led to 936 (15.9%) additional men without osteoporosis being identified as at high fracture risk, raising the total prevalence of men potentially eligible for drug treatment to 25.3%. Observed 10 year hip fracture probabilities were 20.6% for men with osteoporosis by WHO criteria alone, 6.8% for men with osteoporosis by NOF (but not WHO) criteria, 6.4% for men without osteoporosis but classified as at high fracture risk, and 1.5% for men without osteoporosis and classified as at low fracture risk. A similar pattern was noted in observed fracture probabilities for major osteoporotic fracture. Among men with osteoporosis by WHO criteria, observed fracture probabilities were greater than FRAX predicted probabilities (20.6% v 9.5% for hip fracture and 30.0% v 17.4% for major osteoporotic fracture). CONCLUSIONS AND RELEVANCE Choice of definition of osteoporosis and use of NOF derived FRAX intervention thresholds have major effects on the proportion of older men identified as warranting drug treatment to prevent fracture. Among men identified with osteoporosis by WHO criteria, who comprised 2% of the study population, actual observed fracture probabilities during 10 years of follow-up were highest and exceeded FRAX predicted fracture probabilities. On the basis of findings from randomized trials in women, these men are most likely to benefit from treatment. Expanding indications for treatment beyond this small group has uncertain value owing to lower observed fracture probabilities and uncertain benefits of treatment among men not selected on the basis of WHO criteria.
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Affiliation(s)
- Kristine E Ensrud
- Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA Center for Chronic Disease Outcomes Research, VA Health Care System, Minneapolis, MN, USA
| | - Brent C Taylor
- Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA Center for Chronic Disease Outcomes Research, VA Health Care System, Minneapolis, MN, USA
| | - Katherine W Peters
- California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Margaret L Gourlay
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Meghan G Donaldson
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, BC, Canada
| | - William D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Terri L Blackwell
- California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Howard A Fink
- Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA Center for Chronic Disease Outcomes Research, VA Health Care System, Minneapolis, MN, USA
| | - Eric S Orwoll
- Bone and Mineral Unit, Oregon Health and Science University, Portland, OR, USA
| | - John Schousboe
- Park Nicollet Clinic, St Louis Park, MN, USA Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
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330
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Skolarus TA, Wolf AMD, Erb NL, Brooks DD, Rivers BM, Underwood W, Salner AL, Zelefsky MJ, Aragon-Ching JB, Slovin SF, Wittmann DA, Hoyt MA, Sinibaldi VJ, Chodak G, Pratt-Chapman ML, Cowens-Alvarado RL. American Cancer Society prostate cancer survivorship care guidelines. CA Cancer J Clin 2014; 64:225-49. [PMID: 24916760 DOI: 10.3322/caac.21234] [Citation(s) in RCA: 292] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 04/14/2014] [Indexed: 12/15/2022] Open
Abstract
Prostate cancer survivors approach 2.8 million in number and represent 1 in 5 of all cancer survivors in the United States. While guidelines exist for timely treatment and surveillance for recurrent disease, there is limited availability of guidelines that facilitate the provision of posttreatment clinical follow-up care to address the myriad of long-term and late effects that survivors may face. Based on recommendations set forth by a National Cancer Survivorship Resource Center expert panel, the American Cancer Society developed clinical follow-up care guidelines to facilitate the provision of posttreatment care by primary care clinicians. These guidelines were developed using a combined approach of evidence synthesis and expert consensus. Existing guidelines for health promotion, surveillance, and screening for second primary cancers were referenced when available. To promote comprehensive follow-up care and optimal health and quality of life for the posttreatment survivor, the guidelines address health promotion, surveillance for prostate cancer recurrence, screening for second primary cancers, long-term and late effects assessment and management, psychosocial issues, and care coordination among the oncology team, primary care clinicians, and nononcology specialists. A key challenge to the development of these guidelines was the limited availability of published evidence for management of prostate cancer survivors after treatment. Much of the evidence relies on studies with small sample sizes and retrospective analyses of facility-specific and population databases.
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Affiliation(s)
- Ted A Skolarus
- Assistant Professor of Urology, Department of Urology, University of Michigan, Research Investigator, HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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331
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Abstract
OBJECTIVE To review information pertinent to bone health and osteoporosis in men. METHODS A review of pertinent literature was conducted. RESULTS Osteoporosis affects approximately 2 million men in the US and accounts for an estimated 600,000 fractures each year. There are significant differences in skeletal size and structure between men and women that account for differences in fracture incidence, location, and outcomes. Bone density testing is appropriate for men age 70 and older and younger men (50-69) who have risk factors for osteoporosis. Lifestyle management, including adequate calcium and vitamin D intake, appropriate physical activity, and avoidance of tobacco and heavy alcohol use, is appropriate for all men. Pharmacologic therapy to reduce fracture risk is advisable for men with a clinical diagnosis of osteoporosis (a spine or hip fracture) or a T-score of -2.5 or below in the spine, femoral neck, total hip or 1/3 radius; however, the majority of men at high risk will only be identified using a fracture risk assessment tool, such as FRAX. Alendronate, risedronate, zoledronic acid, denosumab, and teriparatide are Food and Drug Administration (FDA)-approved therapeutic options. CONCLUSIONS Osteoporosis in men presents an important public health problem with significant morbidity and mortality. There are recommended strategies for identifying men at high risk of fracture, and effective agents are available for treatment.
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Affiliation(s)
- Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, Ohio
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332
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Anagnostis P, Karras SN, Goulis DG. Monitoring the efficacy of once-weekly teriparatide. Are bone turnover markers useful in predicting fracture risk? Curr Med Res Opin 2014; 30:1177-8. [PMID: 24579907 DOI: 10.1185/03007995.2014.895312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Panagiotis Anagnostis
- Division of Endocrinology, Police Medical Centre of Thessaloniki , Sarantaporou 10, Thessaloniki, 54 640 , Greece
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333
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Tsang DS, Alibhai SM. Bone health care for patients with prostate cancer receiving androgen deprivation therapy. Hosp Pract (1995) 2014; 42:89-102. [PMID: 24769788 DOI: 10.3810/hp.2014.04.1107] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Patients with prostate cancer often receive androgen deprivation therapy (ADT) as part of their treatment regimen. However, treatment with ADT causes multiple side effects, including reduced bone mineral density (BMD), lower lean body mass, and a higher risk for fractures. Several organizations provide clinical practice guidelines for osteoporosis screening, prevention, and treatment in this population, but adherence to these guidelines remains low. Areas for improvement in provider adherence include baseline and follow-up BMD testing, as well as counseling regarding healthy bone behaviors such as calcium/vitamin D intake, lifestyle changes, and physical exercise. Comparison of osteoporosis care in breast cancer and non-oncology populations shows that suboptimal bone health care is not isolated to prostate cancer. A summary of the literature examining improvements in patient adherence and provider delivery of bone health care is included in this review, but high-quality studies are lacking. Patients may be the most receptive to written educational information delivered at or near the time of ADT initiation. Involvement of a primary care practitioner and oncologist in care delivery is associated with higher BMD test use. Institution-level programs that automatically initiate osteoporosis screening and management may be effective at reducing the incidence of hip fracture. Lastly, suggestions are provided for future approaches to knowledge translation and quality of care studies to improve bone health.
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Affiliation(s)
- Derek S Tsang
- Resident Physician, Department of Radiation Oncology, University of Toronto, Toronto, Canada
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334
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Borges CN, de Almeida JM, Lima D, Cabral M, Bandeira F. Prevalence of morphometric vertebral fractures in old men and the agreement between different methods in the city of Recife, Brazil. Rheumatol Int 2014; 34:1387-94. [PMID: 24807694 DOI: 10.1007/s00296-014-3035-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 04/23/2014] [Indexed: 10/25/2022]
Abstract
Osteoporosis is relatively common in men and has a great impact on quality of life. Despite the importance of the subject, there are few studies regarding the prevalence of morphometric vertebral fractures in men and the associated risk factors. To determine the prevalence of morphometric vertebral fractures in elderly men by three different methods and the agreement between them, 234 asymptomatic men aged >60 years (mean age 69.4 ± 6.5 years) were evaluated using lateral thoracolumbar radiograph that were analyzed by two experienced radiologists according to semiquantitative (SQ) Genant and algorithm-based qualitative (ABQ) Jiang methods. A third senior radiologist adjudicated Genant's method. The highest prevalence of fractures in ABQ Jiang and SQ Genant methods were 37.6 and 36.8 %, respectively (both examiner 2). The lowest prevalence rates were 26.5 % in ABQ Jiang method and 5.6 % in SQ Genant (both examiner 1). The prevalence found by the Genant adjudicated was 31.6 %. The agreement between the examiners were 69.2 % in ABQ Jiang method (κ 0.30; 95 % CI 0.17-0.43) and 65.5 % in SQ Genant (κ 0.09; 95 % CI 0.01-0.17). We evaluated skin phototype, waist circumference, hypertension, body mass index (BMI), history of fracture, calcium intake, serum 25 OHD and sun index. After multivariate regression analysis, we found that lower BMI (prevalence ratio = 1.41; p = 0.024; 95 % CI 1.05-2.03) and sun index (prevalence ratio = 1.45; p = 0.049; 95 % CI 1.01-1.95) were independently associated with morphometric vertebral fractures.
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Affiliation(s)
- Carla Nubia Borges
- Division of Endocrinology, Diabetes and Bone Disease, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Rua Marechal Rondon, 120, apto 1602, Recife, Pernambuco, CEP: 52061-050, Brazil
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335
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Osteoporosis in men: a review. Bone Res 2014; 2:14001. [PMID: 26273515 PMCID: PMC4472130 DOI: 10.1038/boneres.2014.1] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 01/20/2014] [Accepted: 01/24/2014] [Indexed: 01/12/2023] Open
Abstract
Osteoporosis and consequent fracture are not limited to postmenopausal women. There is increasing attention being paid to osteoporosis in older men. Men suffer osteoporotic fractures about 10 years later in life than women, but life expectancy is increasing faster in men than women. Thus, men are living long enough to fracture, and when they do the consequences are greater than in women, with men having about twice the 1-year fatality rate after hip fracture, compared to women. Men at high risk for fracture include those men who have already had a fragility fracture, men on oral glucocorticoids or those men being treated for prostate cancer with androgen deprivation therapy. Beyond these high risk men, there are many other risk factors and secondary causes of osteoporosis in men. Evaluation includes careful history and physical examination to reveal potential secondary causes, including many medications, a short list of laboratory tests, and bone mineral density testing by dual energy X-ray absorptiometry (DXA) of spine and hip. Recently, international organizations have advocated a single normative database for interpreting DXA testing in men and women. The consequences of this change need to be determined. There are several choices of therapy for osteoporosis in men, with most fracture reduction estimation based on studies in women.
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336
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Gibb FW, Strachan MWJ. Androgen deficiency and type 2 diabetes mellitus. Clin Biochem 2014; 47:940-9. [PMID: 24768826 DOI: 10.1016/j.clinbiochem.2014.04.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 04/02/2014] [Accepted: 04/04/2014] [Indexed: 01/14/2023]
Abstract
The rising incidence of T2DM is well recognised and associated with trends in obesity and ageing. It is estimated that 2.8% of the world population had a diagnosis of diabetes mellitus in 2000, which is projected to rise to 4.3% by 2030. Diabetes, obesity and ageing are also associated with an increased risk of isolated male hypogonadotropic hypogonadism, often labelled 'late onset hypogonadism' (LOH) to distinguish it from hypogonadism secondary to distinct hypothalamopituitary pathology. Whether the incidence of hypogonadism is increasing is open to question; the past decade, however, has witnessed a marked increase in the prescription of testosterone replacement therapy. Testosterone deficiency appears to be particularly common in type 2 diabetes with a prevalence of 33% observed in one cohort of 103 men (mean age 54.7). However, the diagnosis of androgen deficiency states is not necessarily straightforward, depending amongst other factors, upon whether a biochemical threshold or a syndromic approach (mandating the presence of certain key clinical features) is employed. The pathogenic mechanisms underlying obesity and diabetes related hypogonadism remain unclear with several competing theories, most of which are not mutually exclusive. Whilst a large body of epidemiological evidence associates testosterone deficiency with increased risk of cardiovascular disease and mortality, little evidence exists to support a protective effect of testosterone replacement. The benefits of androgen replacement in younger men with pituitary disease are well established, however, the potential benefits and safety of androgen replacement in older men is much less well developed. At present, replacement therapy in older men is advocated principally for the amelioration of sexual symptoms. This review will seek to explore issues around the pathogenesis, diagnosis, clinical consequences and management of male hypogonadism as it relates to T2DM.
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Affiliation(s)
- Fraser W Gibb
- Edinburgh Centre for Endocrinology and Diabetes, UK.
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337
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Korpi-Steiner N, Milhorn D, Hammett-Stabler C. Osteoporosis in men. Clin Biochem 2014; 47:950-9. [PMID: 24726494 DOI: 10.1016/j.clinbiochem.2014.03.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 03/24/2014] [Accepted: 03/29/2014] [Indexed: 12/11/2022]
Abstract
Osteoporosis in men causes significant morbidity and mortality. Bone health declines gradually, often insidiously; and in light of the advancing aging population poses a serious public health issue that is not well recognized. Studies of the past decade have expanded our understanding of the events within, as well as the regulation of, bone remodeling and provided better insight into the physiology and pathophysiology specific to the adult male skeleton. The clinical measurement of bone mineral density using dual-energy X-ray absorptiometry remains the gold standard for diagnosis of osteoporosis in males; and fracture risk assessment is now recognized as a preferred approach to guide treatment decisions. Utilizing surrogate end-points such as increasing bone mineral density and decreasing concentrations of bone resorption markers, clinical trials have demonstrated efficacy in pharmacological treatment of osteoporosis in the adult male. Unfortunately, few studies have evaluated the anti-fracture benefits in this population. Measurement of bone turnover markers may be an additional tool to monitor therapeutic responsiveness in addition to the measurement of bone mineral density.
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Affiliation(s)
- Nichole Korpi-Steiner
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Denise Milhorn
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Catherine Hammett-Stabler
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA.
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338
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Sidlauskas KM, Sutton EE, Biddle MA. Osteoporosis in men: epidemiology and treatment with denosumab. Clin Interv Aging 2014; 9:593-601. [PMID: 24748777 PMCID: PMC3986279 DOI: 10.2147/cia.s51940] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Osteoporosis is a major public health care concern. Although often described as a disease affecting postmenopausal women, researchers and clinicians have emphasized its prevalence in men in recent years. The National Osteoporosis Foundation has stated that up to 25% of men over the age of 50 years will experience a fracture due to osteoporosis. Men who suffer from a major fracture have higher mortality rates than women. Pharmacologic therapy options for treating osteoporosis are limited for men as compared with women, so each medication approved for use in this population represents an important clinical option. In September 2012, the US Food and Drug Administration approved a new indication for denosumab to increase bone mass in men with osteoporosis at high risk for fracture. Denosumab is a fully human monoclonal antibody and novel antiresorptive agent that works by binding receptor activator of nuclear factor kappa-β ligand (RANKL) and inhibiting the signaling cascade that causes osteoclast maturation, activity, and survival. Ultimately, denosumab suppresses bone turnover and increases bone mineral density in both trabecular and cortical bone. Approval for treating osteoporosis in men was based on data from the ADAMO trial which displayed efficacy in increasing bone mineral density at the lumbar spine, total hip, femoral neck, hip trochanter, and one-third radius. Studies indicate that denosumab is effective and safe, and has superior adherence rates and patient satisfaction. Although long-term data and further research on fracture reduction rates in men should be explored, at this time denosumab is one of several appropriate first-line treatment options for men with osteoporosis.
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Affiliation(s)
- Kristel M Sidlauskas
- Albany College of Pharmacy and Health Sciences-Vermont Campus, Colchester, VT, USA
| | - Emily E Sutton
- Albany College of Pharmacy and Health Sciences-Vermont Campus, Colchester, VT, USA
| | - Michael A Biddle
- Albany College of Pharmacy and Health Sciences-Vermont Campus, Colchester, VT, USA
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339
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Documento de consenso: Recomendaciones para el manejo de la enfermedad ósea metabólica en pacientes con virus de la inmunodeficiencia humana. Enferm Infecc Microbiol Clin 2014; 32:250-8. [DOI: 10.1016/j.eimc.2013.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 07/03/2013] [Indexed: 12/20/2022]
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340
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Vesper HW, Botelho JC, Vidal ML, Rahmani Y, Thienpont LM, Caudill SP. High variability in serum estradiol measurements in men and women. Steroids 2014; 82:7-13. [PMID: 24407040 PMCID: PMC5699465 DOI: 10.1016/j.steroids.2013.12.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 12/10/2013] [Accepted: 12/19/2013] [Indexed: 11/18/2022]
Abstract
To reduce the variability in estradiol (E2) testing and to assure better patient care, standardization of E2 measurements has been recommended. This study aims to assess the accuracy and variability of E2 measurements performed by 11 routine immunological methods and 6 mass spectrometry methods using single donor serum materials and to compare the results to a reference method. The contribution of calibration bias, specificity or matrix effects, and imprecision on the overall variability of individual assays was evaluated. This study showed substantial variability in serum E2 measurements in samples from men and pre- and post-menopausal women. The mean bias across all samples, for each participant, ranged between -2.4% and 235%, with 3 participants having a mean bias of over 100%. The data suggest that calibration bias is the major contributor to the overall variability for nine assays. The analytical performances of most assays measuring E2 concentrations do not meet current needs in research and patient care. Three out of 17 assays would meet performance criteria derived from biological variability of ±12.5% bias at concentrations ≥20 pg/mL, and a maximum allowable bias of ±2.5 pg/mL at concentrations <20 pg/mL. The sensitivity differs highly between assays. Most assays are not able to measure E2 levels below 10 pg/mL. Standardization, specifically calibration to a common standard by using panels of individual patient samples, can reduce the observed variability and improve the utility of E2 levels in clinical settings.
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Affiliation(s)
- Hubert W Vesper
- Centers for Disease Control and Prevention, 4770 Buford Highway, NE F25, Atlanta 30341-3724, Georgia.
| | - Julianne C Botelho
- Centers for Disease Control and Prevention, 4770 Buford Highway, NE F25, Atlanta 30341-3724, Georgia
| | - Meghan L Vidal
- Centers for Disease Control and Prevention, 4770 Buford Highway, NE F25, Atlanta 30341-3724, Georgia
| | - Yasamin Rahmani
- Centers for Disease Control and Prevention, 4770 Buford Highway, NE F25, Atlanta 30341-3724, Georgia
| | | | - Samuel P Caudill
- Centers for Disease Control and Prevention, 4770 Buford Highway, NE F25, Atlanta 30341-3724, Georgia
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341
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Adherence and efficacy of screening for low bone mineral density among ulcerative colitis patients treated with corticosteroids. Am J Gastroenterol 2014; 109:572-8. [PMID: 24469613 DOI: 10.1038/ajg.2013.486] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 12/10/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Ulcerative colitis (UC) is associated with an increased risk of metabolic bone disease and fragility fractures. The aim of this study was to assess the adherence to the guidelines issued by the American Gastroenterology Association (AGA) for the screening for low bone density in UC patients and to assess the benefits of dual-energy X-ray absorptiometry (DXA) screening among corticosteroid (CS)-treated UC patients. METHODS Nationwide Veterans Affairs system (VA) data were obtained. UC patients followed up in the VA between 2001 and 2011 and the occurrence of fragility fractures were identified using International Classification of Diseases, Ninth Revision codes. Exposure to CSs was assessed using pharmacy data. DXA screening was assessed using the VA procedure database. Post DXA screening, medication use was also assessed from the pharmacy database. Cox regression analysis was performed to calculate the hazard ratio (HR) of fragility fractures among those patients who received DXA compared with those who did not. RESULTS We included 5,736 patients. Among them, 80 (1.4%) patients suffered from fragility fractures during the follow-up period. Overall adherence rate to AGA guidelines was 23%. Adherence rate was highest among postmenopausal women (48%) and lowest among men above 50 years of age (20%). UC patients who received DXA screening were more likely to be started on bisfosfonates (P<0.001), calcitonin (P<0.001), vitamin D, and calcium (P<0.001) compared with those who did not receive screening. Those who received DXA screening were half as likely (HR=0.5, 0.3-0.9, P=0.03) to develop fragility fractures as compared with those who did not receive screening. The benefits were more prominent among those with higher CS exposure. CONCLUSIONS Rates of DXA screening were low among CS-treated UC patients. Those who received DXA screening were more likely to be started on antiresorptive therapy and supplemental medications and had a 50% reduction in the risk of fragility fractures. More efforts should be directed toward raising the adherence to AGA guidelines and the awareness of DXA benefits.
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342
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Schousboe JT, Tanner SB, Leslie WD. Definition of osteoporosis by bone density criteria in men: effect of using female instead of male young reference data depends on skeletal site and densitometer manufacturer. J Clin Densitom 2014; 17:301-6. [PMID: 24269168 DOI: 10.1016/j.jocd.2013.09.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 09/05/2013] [Indexed: 10/26/2022]
Abstract
Whether to use young male or young female reference data to calculate bone mineral density (BMD) T-scores in men remains controversial. The third National Health and Nutrition Examination and Survey (NHANES III) data show that the mean and standard deviation of femoral neck and total hip BMD is greater in young men than young women, and therefore differences in T-scores at these sites using NHANES III female vs male norms becomes less as BMD decreases. In contrast, manufacturer-specific reference databases generally assume similar standard deviations of BMD in men and women. Using NHANES III reference data for the femoral neck and total hip, respectively we found that men with T-scores of -2.5 when young male norms are used have T-scores of -2.4 and -2.3 when young female norms are used. Using manufacturer-specific reference data, we found that men with T-scores of -2.5 when young male norms are used at the femoral neck, total hip, lumbar spine, or one-third of the forearm would have T-scores ranging from -2.4 to -0.4 when young female norms are used, depending on skeletal site and densitometer manufacturer. The change of proportions of men diagnosed with osteoporosis when young female norms are used instead of young male reference data differs substantially according to skeletal site and densitometer manufacturer.
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Affiliation(s)
- John T Schousboe
- Park Nicollet Osteoporosis Center and Institute for Research and Education, Minneapolis, MN, USA; Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA.
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343
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Jensen AL, Lomborg K, Wind G, Langdahl BL. Effectiveness and characteristics of multifaceted osteoporosis group education--a systematic review. Osteoporos Int 2014; 25:1209-24. [PMID: 24270886 DOI: 10.1007/s00198-013-2573-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 10/31/2013] [Indexed: 11/26/2022]
Abstract
UNLABELLED The characteristics and effectiveness of osteoporosis multifaceted group education were determined from a systematic review of international literature. Findings showed that these educational programmes may be beneficial in a variety of important factors for the prevention, treatment and management of osteoporosis. INTRODUCTION This systematic review investigated quantitative studies on osteoporosis multifaceted group education. The purpose was to investigate the characteristics as well as the effectiveness of this form of osteoporosis patient education. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses guided this systematic review. Relevant databases were searched until January 2013. RESULTS Seven studies published between 1993 and 2011 including osteoporosis patients with or without fractures were found. The multifaceted educational programmes all consisted of three overall themes: (1) Knowledge of osteoporosis, (2) Medication and diet and (3) Exercise, but with different foci across the studies. Overall, 24 outcome measures representing six topics were applied: (1) Health-related quality of life, (2) Psychosocial function, (3) Pain, (4) Physical activity, (5) Knowledge and (6) Medication and diet. The review showed that multifaceted osteoporosis group education can increase the patients' knowledge of osteoporosis as well as their health-related quality of life, physical activity and psychosocial functioning. It has the potential to increase adherence to both pharmacological and non-pharmacological treatments. CONCLUSIONS Multifaceted group education may have a positive impact on the patients' ability to engage in preventing and managing osteoporosis. Further research directed towards the complexity of multifaceted group education is needed. In addition, research investigating the educational needs of specific groups of osteoporotic patients is required.
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Affiliation(s)
- A L Jensen
- Faculty of Health Sciences, Department of Public Health, Section of Nursing, Aarhus University, Hoegh-Guldbergs Gade 6A, Building 1633, 8000, Aarhus C, Denmark,
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344
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Affiliation(s)
- Se Hwa Kim
- Department of Internal Medicine, Kwandong University College of Medicine, Incheon, Korea
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345
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Vesper HW, Botelho JC, Wang Y. Challenges and improvements in testosterone and estradiol testing. Asian J Androl 2014; 16:178-84. [PMID: 24407184 PMCID: PMC3955326 DOI: 10.4103/1008-682x.122338] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 08/08/2013] [Indexed: 11/04/2022] Open
Abstract
Assays that measure steroid hormones in patient care, public health, and research need to be both accurate and precise, as these criteria help to ensure comparability across all clinical and research applications. This review addresses major issues relevant to assay variability and describes recent activities by the US Centers for Disease Control and Prevention (CDC) to improve assay performance. Currently, high degrees of accuracy and precision are not always met for testosterone and estradiol measurements; although technologies for steroid hormone measurement have advanced significantly, measurement variability within and across laboratories has not improved accordingly. Differences in calibration and specificity are discussed as sources of variability in measurement accuracy. Ultimately, a combination of factors appears to cause inaccuracy of steroid hormone measurements, with nonuniform assay calibration and lack of specificity being two major contributors to assay variability. Within-assay variability for current assays is generally high, especially at low analyte concentrations. The CDC Hormone Standardization (HoSt) Program is improving clinical assays, as evidenced by a 50% decline in mean absolute bias between mass spectrometry assays and the CDC reference method from 2007 to 2011. This program provides the measurement traceability to CDC reference methods and helps to minimize factors affecting measurement variability.
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Affiliation(s)
- Hubert W Vesper
- Clinical Chemistry Branch, Division of Laboratory Sciences, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Julianne C Botelho
- Clinical Chemistry Branch, Division of Laboratory Sciences, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Yuesong Wang
- Clinical Chemistry Branch, Division of Laboratory Sciences, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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346
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Poulsen MH, Frost M, Abrahamsen B, Brixen K, Walter S. Osteoporosis and prostate cancer: a cross-sectional study of Danish men with prostate cancer before androgen deprivation therapy. Scand J Urol 2014; 48:350-5. [DOI: 10.3109/21681805.2014.884160] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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347
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García B. CE. Salud del hombre mayor: más allá de la urología. REVISTA MÉDICA CLÍNICA LAS CONDES 2014. [DOI: 10.1016/s0716-8640(14)70015-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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348
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Osteoporosis in healthy South Indian males and the influence of life style factors and vitamin d status on bone mineral density. J Osteoporos 2014; 2014:723238. [PMID: 25478284 PMCID: PMC4244976 DOI: 10.1155/2014/723238] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/21/2014] [Accepted: 10/22/2014] [Indexed: 11/28/2022] Open
Abstract
Objective. To study the prevalence of osteoporosis and vitamin D deficiency in healthy men and to explore the influence of various life style factors on bone mineral density (BMD) and also to look at number of subjects warranting treatment. Methods. Ambulatory south Indian men aged above 50 were recruited by cluster random sampling. The physical activity, risk factors in the FRAX tool, BMD, vitamin D, and PTH were assessed. The number of people needing treatment was calculated, which included subjects with osteoporosis and osteopenia with 10-year probability of major osteoporotic fracture >20 percent and hip fracture >3 percent in FRAX India. Results. A total of 252 men with a mean age of 58 years were studied. The prevalence of osteoporosis and osteopenia at any one site was 20% (50/252) and 58%, respectively. Vitamin D deficiency (<20 ng/dL) was seen in 53%. On multiple logistic regression, BMI (OR 0.3; P value = 0.04) and physical activity (OR 0.4; P value < 0.001) had protective effect on BMD. Twenty-five percent warranted treatment. Conclusions. A significantly large proportion of south Indian men had osteoporosis and vitamin D deficiency. Further interventional studies are needed to look at reduction in end points like fractures in these subjects.
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Rondanelli M, Guido D, Opizzi A, Faliva MA, Perna S, Grassi M. A path model of sarcopenia on bone mass loss in elderly subjects. J Nutr Health Aging 2014; 18:15-21. [PMID: 24402383 DOI: 10.1007/s12603-013-0357-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Aging is associated with decreases in muscle mass, strength, power (sarcopenia) and bone mineral density (BMD). The aims of this study were to investigate in elderly the role of sarcopenia on BMD loss by a path model, including adiposity, inflammation, and malnutrition associations. METHODS Body composition and BMD were measured by dual X-ray absorptiometry in 159 elderly subjects (52 male/107 female; mean age 80.3 yrs). Muscle strength was determined with dynamometer. Serum albumin and PCR were also assessed. Structural equations examined the effect of sarcopenia (measured by Relative Skeletal Muscle Mass, Total Muscle Mass, Handgrip, Muscle Quality Score) on osteoporosis (measured by Vertebral and Femoral T-scores) in a latent variable model including adiposity (measured by Total Fat Mass, BMI, Ginoid/Android Fat), inflammation (PCR), and malnutrition (serum albumin). RESULTS The sarcopenia assumed a role of moderator in the adiposity-osteoporosis relationship. Specifically, increasing the sarcopenia, the relationship adiposity-osteoporosis (β: -0.58) decrease in intensity. Adiposity also influences sarcopenia (β: -0.18). Malnutrition affects the inflammatory and the adiposity states (β: +0.61, and β: -0.30, respectively), while not influencing the sarcopenia. Thus, adiposity has a role as a mediator of the effect of malnutrition on both sarcopenia and osteoporosis. Malnutrition decreases adiposity; decreasing adiposity, in turn, increase the sarcopenia and osteoporosis. CONCLUSIONS This study suggests such as in a group of elderly sarcopenia affects the link between adiposity and BMD, but not have a pure independent effect on osteoporosis.
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Affiliation(s)
- M Rondanelli
- M. Rondanelli, Department of Public Health, Section of Human Nutrition and Dietetics, Faculty of Medicine, University of Pavia, Endocrinology and Nutrition Unit, ASP, Pavia, Italy, Tel. 0039-0382381749, fax: 0039-0382381218, e-mail:
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Park SE, Oh KW, Lee WY, Baek KH, Yoon KH, Son HY, Lee WC, Kang MI. Association of osteoporosis susceptibility genes with bone mineral density and bone metabolism related markers in Koreans: the Chungju Metabolic Disease Cohort (CMC) study. Endocr J 2014; 61:1069-78. [PMID: 25132170 DOI: 10.1507/endocrj.ej14-0119] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In this study, we evaluated the association between bone mineral density (BMD) and 10 single-nucleotide polymorphisms (SNPs) within eight osteoporosis susceptibility genes that were previously identified in genome-wide association studies (GWASs). A total of 494 men and 493 postmenopausal women participating in the Chungju Metabolic Disease cohort study in Korea were included. The following 10 SNPs were genotyped: ZBTB40 rs6426749, MEF2C rs1366594, ESR1 rs2941740, TNFRSF11B rs3134070, TNFRSF11B rs2073617, SOX6 rs711785, LRP5 rs599083, TNFSF11 rs227438, TNFSF11 rs9594782, and FOXL1 rs10048146; and the association between these SNPs and bone metabolism-related markers was assessed. Two SNPs, TNFSF11 rs2277438 and FOXL1 rs1004816, were associated with lumbar spine BMD. TNFSF11 rs2277438 in men and SOX6 rs7117858 and FOXL1 rs10048146 in postmenopausal women were found to be associated with lumbar BMD. ZBTB40 rs6426749, MEF2C rs1366594, and LRP5 rs599083 showed significant associations with femur neck BMD. These three SNPs in men and MEF2C rs1366594 and ESR1 rs2941740 in postmenopausal women were associated with femur neck BMD. A significant association between MEF2C rs1366594 and serum calcium levels was observed in men. Serum phosphorus levels were related to SOX6 rs7117858. Serum PTH levels were significantly associated with TNFRSF11B rs3134070 in men, and SOX6 rs711858 in postmenopausal women. In conclusion, our study independently confirmed associations between several SNPs: ZBTB40, MEF2C, ESR1, SOX6, LRP5, TNFSF11, and FOXL1 and bone marrow density in the Korean population.
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Affiliation(s)
- Se Eun Park
- Department of Endocrinology and Metabolism, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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