The diagnosis and treatment of male osteoporosis: Defining, assessing, and preventing skeletal fragility in men

A 10-Year Prospective Study of Bone Mineral Density and Bone Turnover in Males and Females With Type 1 Diabetes

CONTEXT

In a previous community-based, cross-sectional study, males with type 1 diabetes (T1D) had lower bone mineral density (BMD) than did matched people without diabetes but females with T1D had normal BMD.

OBJECTIVE

To determine whether BMD in the males continued to decline, the neutral effect of T1D on BMD in females persisted, and whether temporal BMD changes reflected changes in bone turnover markers.

DESIGN

Longitudinal observational study.

SETTING

Urban community.

PATIENTS

Forty-eight of the original 102 original cross-sectional study participants (20 males, 28 females) of mean age 42.0 years and median diabetes duration 14.6 years at baseline who were restudied a mean of 10.3 years later.

MAIN OUTCOME MEASURES

BMD at total hip, femoral neck, lumbar spine (L1 to L4), and distal forearm. Biochemical bone turnover markers.

RESULTS

After adjustment for age, body mass index (BMI), and renal function, there was no temporal change in BMD at the hip or forearm in the males (P ≥ 0.12), but lumbar spine BMD increased (P = 0.009). Females exhibited no statistically significant change in BMD in similar multivariable models that also included postmenopausal status, except a mild increase at the forearm (P = 0.046). Age- and sex-related changes in bone turnover markers paralleled those in general population studies.

CONCLUSIONS

There is a reduction in BMD in males with T1D that occurs early in the course of the disease but then stabilizes. BMD in females with T1D remains similar to that expected for age, BMI, and postmenopausal status.

Increased Bone Mineral Density after Abstinence in Male Patients with Alcohol Dependence

Objective

This study aimed to compare the bone mineral density of male patients with alcohol dependence with that in healthy controls and to assess changes in bone density after abstinence.

Methods

Forty-four inpatients with confirmed the Diagnostic and Statistical Manual of Mental Disorders, fourth edition diagnosis of alcohol abuse and 42 controls were recruited. Bone density was determined with dual-energy X-ray absorptiometry in the lumbar spine as well as in the femoral neck, trochanter, and Ward’s triangle regions of the proximal right femur.

Results

There were no significant differences in age and body mass index between patients with alcohol dependence and healthy controls. In the alcohol dependence group, osteopenia and osteoporosis were found in 54.5% and 34.1% of the patients, respectively, whereas in the control group, the corresponding values were 45.2% and 11.9% (p=0.001). Although the actual bone density in the femur and the corresponding T-scores were significantly lower in the alcohol dependence group, no significant differences were found in the lumbar spine. In both groups, body mass index showed a significant correlation with bone mineral density in all areas. After 3 to 4 years of abstinence, bone density significantly increased in the lumbar and femur.

Conclusion

We conclude that bone mineral density in patients with alcohol dependence was significantly lower than that in healthy controls, and the rates of osteopenia and osteoporosis are higher. Importantly, abstinence from alcohol increases bone density.

High prevalence of secondary factors for bone fragility in patients with a recent fracture independently of BMD

In this study, we demonstrate a high prevalence of secondary factors in patients with a recent fracture independently of bone mineral density (BMD). Our results suggest that patients with a recent fracture should be screened for secondary factors for bone fragility regardless of BMD values.

INTRODUCTION

Secondary factors for bone fragility are common in patients with osteoporosis who have sustained a fracture. The majority of fragility fractures occurs, however, in patients with osteopenia, and it is not known whether secondary factors may contribute to fracture risk in these patients or in those with normal BMD.

METHODS

Prospective cohort study evaluating the prevalence of secondary factors for bone fragility in consecutive patients referred to our fracture liaison service from June 2012 to June 2014 after a recent fracture.

RESULTS

Seven hundred nine patients were included, 201 (28 %) with osteoporosis, 391 (55 %) with osteopenia and 117 (17 %) with normal BMD. Mean age was 66.0 ± 9.8 years, 504 (73 %) were women and 390 (57 %) had one or more underlying secondary factor. Evaluation of clinical risk factors using fracture risk assessment tool (FRAX) identified 38 % of patients with ≥1 secondary factor including smoking (18 %), excessive alcohol use (12 %), glucocorticoid use (12 %) and rheumatoid arthritis (3 %). Laboratory investigations revealed chronic kidney disease in 13 %, monoclonal gammopathy also in 13 % and primary or secondary hyperparathyroidism in 1 and 6 %, respectively. Secondary factors for bone fragility were equally prevalent in patients with osteoporosis, osteopenia or normal BMD.

CONCLUSIONS

Our findings demonstrate a high prevalence of secondary factors for bone fragility in patients who have sustained a recent fracture, independently of BMD. The significant number of documented factors, which were treatable, suggest that patients who sustained a fracture should be screened for secondary factors for bone fragility regardless of BMD values to optimise secondary fracture prevention.

Decreased bone mineral density and periodontal management

The definition of osteoporosis has evolved beyond low bone mineral density to include impaired bone morphology and matrix properties. As such, the subsequent bone density insufficiencies extend beyond the skeletal risks of fracture and have implications for oral health management patients. As our population ages there is a worldwide increase in the risk of decreased bone mineral density and its subsequent morbidity. This makes age an independent risk factor for fracture and decreased bone mineral density. Multiple examinations and diagnostic tests are currently used in combination to develop an algorithm to assess osteoporotic risk. Oral health care professionals should follow these principles and caution should be used in applying a single independent assessment to determine a patient's osteoporotic or bone metabolism risk. Therapeutic approaches for osteoporosis are often divided into nonpharmacological interventions and pharmacological therapies. The periodontist and other oral health care professionals should have a full understanding of the therapeutic options, benefits and implementation of preventive therapies. Bone turnover is a coupled event of bone formation and bone resorption and it is the imbalance of this homeostasis that results in osteoporosis. Based on this uncoupling of bone resorption and formation, osteoporosis or decreased bone mineral density and osteopenia, may be a risk factor for alveolar bone loss in periodontitis. The role of prevention and maintenance with a history of periodontitis and oesteopenia extends beyond biofilm control and should include management of bone mineral density. The chronic periodontal infection in a patient with osteopenia may place the patient at greatly increased risk for alveolar bone loss, gingival recession and root caries. A key component in the management is the oral health professional's knowledge of the interrelationship between skeletal health and periodontal health.

Idiopathic osteoporosis in men

Over the last decade, the increasingly significant problem of osteoporosis in men has begun to receive much more attention than in the past. In particular, recent observations from large scale population studies in males led to an advance in the understanding of morphologic basis of growth, maintenance and loss of bone in men, as well as new insights about the pathophysiology and treatment of this disorder. While fracture risk consistently increases after age 65 in men (with up to 50 % of cases due to secondary etiologies), osteoporosis and fractures may also occur in young or middle aged males in the absence of an identifiable etiology. For this category (so called idiopathic osteoporosis), there are still major gaps in knowledge, particularly concerning the etiology and the clinical management. This article provides a summary of recent developments in the acquisition and maintenance of bone strength in men, as well as new insights about the pathogenesis, diagnosis, and treatment of idiopathic osteoporosis.

A five-year prospective study of bone mineral density in men and women with diabetes: the Fremantle Diabetes Study

To examine longitudinally the effect of diabetes on bone structure and metabolism, we measured bone mineral density (BMD) and turnover markers in 26 type 1 (mean age 49 years) and 27 type 2 (mean age 65 years) diabetic patients without known osteoporosis from a community-based sample at baseline and 5 years later. In the 17 type 1 men, BMD fell at the femoral neck (0.804 ± 0.145 vs. 0.769 ± 0.129 g/cm(2); P = 0.003) with no change at lumbar spine or forearm. In the 11 type 2 women, BMD decreased at all sites except spine (femoral neck 0.779 ± 0.119 vs. 0.742 ± 0.090 g/cm(2); P = 0.019). BMD did not fall at any site in type 1 women or type 2 men. There was an increase in serum alkaline phosphatase and trend to higher serum beta carboxyl-terminal type I collagen telopeptide concentrations in the type 1 patients, and a decrease in free testosterone in the type 1 men. These data show that the rate of demineralization at the femoral neck in type 1 men is similar to that in older post-menopausal type 2 women. Changes in biochemical markers suggest that, in type 1 men, there is ineffective bone formation associated with accelerated bone resorption and lower sex steroid bioavailability. These findings may have implications for the clinical management of young male adults with diabetes.

Prevalence of thoracic vertebral fractures in Spanish patients hospitalized in Internal Medicine Departments. Assessment of the clinical inertia. (PREFRAMI study)

PURPOSE

To study the prevalence of vertebral fractures (VF), the associated risk factors and the degree of diagnosis and prescription upon discharge in a series of hospitalized medical patients ≥50 years of age.

METHODS

A cross-sectional, multicentre and observational study in which a prevalence cut-off was carried out concerning patients admitted to six Internal Medicine departments in Malaga (Spain). The main variables were the existence of a fracture in the spine lateral x-ray, the inclusion of the diagnosis of a fracture in the discharge report, and the establishment of anti-osteoporotic treatment at discharge.

RESULTS

254 patients were included (mean age 66.4±14.9 years). The prevalence of VF was of 14.2% (36 cases). Patients with VF presented with a higher mean age, compared to those without VF (70.14 vs. 65.7 years) (p=0.035). The means contrast for the FRAX index variable (major osteoporotic and hip fracture), grouping according to the presence of VF, did not show any statistical significance (p=0.369 and p=0.788, respectively). Only in 8.3% of the discharge reports of patients with VF had the diagnosis of VF and/or osteoporosis been recorded and the prescription of anti-osteoporotic drugs been included.

CONCLUSIONS

A high prevalence of asymptomatic VF is verified in medical inpatients ≥50 years of age. The FRAX index did not turn out to be predictive of the presence of VF in this population. There is an underdiagnosis of osteoporotic VF in the coding at hospital discharge. Action protocols are necessary to avoid clinical inactivity regarding this entity.

Osteoporotic fracture and parathyroid hormone

Osteoporosis and age-related bone loss is associated with changes in bone remodeling characterized by decreased bone formation relative to bone resorption, resulting in bone fragility and increased risk of fractures. Stimulating the function of bone-forming osteoblasts, is the preferred pharmacological intervention for osteoporosis. Recombinant parathyroid hormone (PTH), PTH(1-34), is an anabolic agent with proven benefits to bone strength and has been characterized as a potential therapy for skeletal repair. In spite of PTH's clinical use, safety is a major consideration for long-term treatment. Studies have demonstrated that intermittent PTH treatment enhances and accelerates the skeletal repair process via a number of mechanisms. Recent research into the molecular mechanism of PTH action on bone tissue has led to the development of PTH analogs to control osteoporotic fractures. This review summarizes a number of advances made in the field of PTH and bone fracture to combat these injuries in humans and in animal models. The ultimate goal of providing an alternative to PTH, currently the sole anabolic therapy in clinical use, to promote bone formation and improve bone strength in the aging population is yet to be achieved.

What Do Israeli Osteoporotic Men Know and Do about Their Disease?

Aims. The aims of the current study were to evaluate the level of knowledge about osteoporosis among osteoporotic men and to assess the correlations with their health behaviors. Method. A convenience sample of 100 osteoporotic men (mean age 63) attending the bone and mineral clinic at a major medical center in Israel was recruited in 2004. Participants were interviewed by phone using an adapted version of the Facts on Osteoporosis Quiz (FOOQ). Participants were also asked to report on their daily calcium intake and participation in physical activities. Results. The overall level of knowledge about the disease demonstrated by the participants was moderate. Higher education, older age, and fewer fractures were correlated with a higher level of knowledge. In addition, higher levels of education and knowledge were correlated with higher calcium intake. Lastly, a higher knowledge level, older age, and fewer fractures were correlated with higher participation in physical activities. Conclusions. Given the correlations between health behaviors and the level of knowledge among osteoporotic men, intervention programs should be used to evaluate and improve knowledge about osteoporosis, especially among less educated patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effectiveness of intermittent rat parathyroid hormone (1-34) treatment on low bone mass due to oestrogen or androgen depletion in skeletally mature rats

Rat parathyroid hormone (PTH) 1-34 (4 microg/kg/day) was applied for 2.5 months to 9 month-old rats immediately after ovariectomy or orchidectomy or to 15 month-old rats with low bone mass which had been castrated 6 months before in order to know the effects on serum biochemistry parameters, lumbar and femoral bone mineral density, histology, cancellous and cortical bone histomorphometry, mineralisation content profile in cortical bone by backscattered-electron microscopy, and femoral torsion biomechanical testing. In ovariectomised rats, preventive PTH treatment avoided cancellous bone loss in tibial metaphysis and partially in lumbar vertebra, while in cortical bone, PTH increased endosteal resorption and periosteal formation. In intervention study, PTH did not restore cancellous bone but a strong endosteal and periosteal new bone formation was detected. In orchidectomised rats, PTH, in preventive study, avoided cancellous bone loss in metaphysis and lumbar vertebra, and a mild new bone formation in cortical bone was found. In intervention study, PTH maintained baseline cancellous bone mass, but in cortical bone a strong endosteal and periosteal new bone formation was detected. The PTH-induced new bone formation was confirmed by histology and by mineral content profiles. After castration, biomechanical properties were affected in females but not in male rats and PTH reverted this effect.

Androgen receptor disruption increases the osteogenic response to mechanical loading in male mice

In female mice, estrogen receptor-alpha (ERalpha) mediates the anabolic response of bone to mechanical loading. Whether ERalpha plays a similar role in the male skeleton and to what extent androgens and androgen receptor (AR) affect this response in males remain unaddressed. Therefore, we studied the adaptive response of in vivo ulna loading in AR-ERalpha knockout (KO) mice and corresponding male and female single KO and wild-type (WT) littermates using dynamic histomorphometry and immunohistochemistry. Additionally, cultured bone cells from WT and AR KO mice were subjected to mechanical loading by pulsating fluid flow in the presence or absence of testosterone. In contrast with female mice, ERalpha inactivation in male mice had no effect on the response to loading. Interestingly, loading induced significantly more periosteal bone formation in AR KO (+320%) and AR-ERalpha KO mice (+256%) compared with male WT mice (+114%) and had a stronger inhibitory effect on SOST/sclerostin expression in AR KO versus WT mice. In accordance, the fluid flow-induced nitric oxide production was higher in the absence of testosterone in bone cells from WT but not AR KO mice. In conclusion, AR but not ERalpha activation limits the osteogenic response to loading in male mice possibly via an effect on WNT signaling.

Anti-fracture efficacy of risedronic acid in men: A meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Male osteoporosis is an important public health issue and remains undertreated. We performed this meta-analysis to clarify the anti-fracture efficacy of risedronic acid in men.

METHODS

Randomized controlled trials (RCTs) in men receiving risedronic acid or placebo published between 1980 and September 2008 were searched for in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. Studies with a follow-up of at least 12 months and providing the incidence of fractures were considered for inclusion in the review. Two independent reviewers assessed the methodological quality of the included studies and performed data extraction. Analysis of pooled data was carried out using Revman 4.2 software.

RESULTS

Four RCTs met the inclusion criteria and permitted a pooled estimate of effectiveness. Relative risk with 95% confidence intervals for pooled effect under fixed effects model were: 0.31 (0.16, 0.60) for vertebral fractures and 0.40 (0.23, 0.70) for nonvertebral fractures, suggesting a 69% risk reduction of vertebral fractures and a 60% risk reduction of nonvertebral fracture with risedronic acid treatment in men.

CONCLUSION

The results of this meta-analysis show that risedronic acid treatment is associated with a reduced risk of fractures in men.

Overcoming barriers to osteoporosis care in vulnerable elderly patients with hip fractures

Indications for and benefits of providing osteoporosis (OP) care for hip fracture patients have become widely understood. The hip fracture patient is frequently over age 80 years, minimally ambulatory, has multiple medical comorbidities, and has cognitive impairment. Patient barriers to initiation of effective OP treatment include: age, dementia, medical comorbidities, polypharmacy, lack of adherence with treatment, alcohol abuse, postoperative delirium, language barriers, inadequate social support, and socioeconomic status. In a large teaching hospital, 244 patients presented with hip fracture over 2 years: 72% were female and 64% were over age 80. Forty percent had been diagnosed with dementia; another 29% had other severe medical comorbidities.Opportunities for OP diagnosis and treatment are numerous. In acute care hospitals, coordinator facilitated programs are effective for identification, education, assessment, referral, and treatment of underlying OP in fracture patients. System modifications may include an automated care path or automatic specialist referral for hip fracture patients. In the rehabilitation hospital, the patients are in a more stable condition, there is a focus on the recent fracture, and there are opportunities to initiate OP treatment and to promote adherence. In long-term care, dietary intake including calcium and vitamin D supplementation and persistence with pharmacotherapy can be monitored. Patient education and referral to the family physician for osteoporosis investigation and treatment have improved patient knowledge and diagnosis, but the reported impact on treatment has been limited.Effective OP care for the vulnerable hip fracture patient should be initiated early but may be complex and require coordination. In addition to calcium and vitamin D supplementation, most patients in this category have an indication for aminobisphosphonate therapy. Liaison between the orthopaedic team and the discharge destination caregivers, an established discharge diagnosis of osteoporosis, and ensuring patients are discharged on supplements and medication will promote patient, caregiver, and primary care physician awareness of the patient's OP care needs. Education programs may provide benefits at later stages, to improve adherence with treatment.

Osteoporosis in men

About one in three osteoporotic fractures occur in men, and the consequences of fractures are more severe in men. However, only too few men at high risk of fracture are detected and treated. There is no consensus definition of osteoporosis in men based on bone mineral density (BMD), and therapeutic decisions should be based on absolute fracture risk as estimated from age, BMD, fracture history, and additional clinical risk factors. In men, secondary osteoporosis deserves particular attention. Genetically determined alterations of bone mass acquisition during growth are involved in idiopathic osteoporosis in the young, whereas senile osteoporosis involves progressive bone loss throughout adult life. Estradiol appears to be the predominant sex steroid involved in regulation of bone maturation and metabolism. The evidence base for the long-term efficacy and safety of therapies for osteoporosis in men, including the bone-active agents (i.e. bisphosphonates and teriparatide), is limited, so that they should be applied with discernment based on clinical judgement and careful estimation of fracture risk.

Differential regulation of bone and body composition in male mice with combined inactivation of androgen and estrogen receptor-alpha

Osteoporosis and muscle frailty are important health problems in elderly men and may be partly related to biological androgen activity. This androgen action can be mediated directly through stimulation of the androgen receptor (AR) or indirectly through stimulation of estrogen receptor-alpha (ERalpha) following aromatization of androgens into estrogens. To assess the differential action of AR and ERalpha pathways on bone and body composition, AR-ERalpha double-knockout mice were generated and characterized. AR disruption decreased trabecular bone mass, whereas ERalpha disruption had no additional effect on the AR-dependent trabecular bone loss. In contrast, combined AR and ERalpha inactivation additionally reduced cortical bone and muscle mass compared with either AR or ERalpha disruption alone. ERalpha inactivation--in the presence or absence of AR--increased fat mass. We demonstrate that AR activation is solely responsible for the development and maintenance of male trabecular bone mass. Both AR and ERalpha activation, however, are needed to optimize the acquisition of cortical bone and muscle mass. ERalpha activation alone is sufficient for the regulation of fat mass. Our findings clearly define the relative importance of AR and ERalpha signaling on trabecular and cortical bone mass as well as body composition in male mice.

The osteoporosis needs of patients with wrist fracture

OBJECTIVES

To provide information for practitioners regarding the osteoporosis (OP)-related needs of patients who present with low-trauma wrist fractures and are at high risk of subsequent hip fracture.

DESIGN

Prospective protocol, retrospective analysis.

SETTING

Large urban teaching hospital, regional trauma center.

PATIENTS

All outpatients (women > or =40 years; men > or =50 years) who sustained fragility fractures of the wrist between December 1, 2002 and June 30, 2005.

INTERVENTION

Patients were evaluated by a coordinator and recruited to an OP program for education, diagnosis, and treatment. Patient demographic data were collected. A baseline questionnaire included fracture and OP risk history, sociodemographics, Osteoporosis Health Beliefs Scale, and Osteoporosis Self-Efficacy Scale.

MAIN OUTCOME MEASURES

Fracture history, OP risk factors, attitudes, and beliefs.

RESULTS

Of 339 patients with wrist fractures, 286 had fragility fractures (mean age 64.8 years; 82% female) and met the age criteria. Seventeen percent of men and 36% of women with fragility wrist fractures had been previously diagnosed with OP or osteopenia; nearly all of them had been prescribed supplements, and two thirds had received aminobisphosphonate treatment for OP. Half of the patients had one or more risk factors for OP. Most patients were aware of OP, but few felt their fracture could result from OP. Bone densitometry completed on 55 patients in the first year indicated OP or osteopenia in 43 of 55 patients. Patients' health beliefs underestimated the seriousness of OP. Every patient with a fragility fracture of the wrist should understand that: (1) their fracture may be related to OP; (2) by having a fragility fracture, they are at higher risk for hip fracture; and (3) preventive treatment is effective and safe. Information should be partly gender specific. Patients who believe that weak bones didn't cause their fracture require additional attention to motivate them to undergo special treatment.

CONCLUSIONS

Intervention by the orthopaedic team to address potential underlying OP in patients with low-trauma wrist fractures should include directed patient education, testing, treatment with supplements and pharmacotherapy where indicated, and referral as needed.

Geographical variation in DXA bone mineral density in young European men and women. Results from the Network in Europe on Male Osteoporosis (NEMO) study

We collected population-based young normal hip and spine BMD data from 17 centres across Europe to assess between centre differences and to compare reference values with the US NHANES-III data. There was strong evidence of between country heterogeneity, but not between centres within countries. Hip BMD mean values were lower in European women, but SD's differed little from the NHANES-III USA results in both sexes. It may be necessary to adjust NHANES-III based T-scores by adding/subtracting a country-specific adjustment factor.

INTRODUCTION

It remains unclear whether young normal BMD reference values specific to an American population can be validly used for T-score calculation in Europeans.

METHODS

We collected population based BMD data from 1163 men and 329 women aged 19-29 years from 17 centres across Europe to compare mean and SD values with the NHANES-III study USA results. BMD(g/cm2) was measured at the hip and spine using DXA densitometers cross-calibrated with the European Spine Phantom (ESP). The only exclusions were for technically inadequate scans. A linear regression model was used to derive reference values. To allow for direct comparison with published NHANES III study data, the cross-calibrated BMD values were converted using the ESP equations to Hologic QDR 1000 units.

RESULTS

In men, the overall mean(SD) BMD values expressed in Hologic-QDR1000 units of measurement, were: femoral neck 0.912(0.132); trochanter 0.793(0.124); and L2-L4 spine 1.027(0.123). The respective estimates in women were: 0.826(0.115); 0.670(0.093); and 0.983(0.107). However the I2 statistic for heterogeneity indicated moderate to strong evidence of between-centre heterogeneity. There was, however, no significant heterogeneity observed between centres within countries, suggesting that this variation arose from national differences. Compared to the NHANES III population-based US data, the mean values in women were significantly lower at both sites due to some lower national European means. However, at all sites and in both sexes the SD's were very similar between the US and Europe. There was some evidence that recruiting volunteers resulted in biased values in women.

CONCLUSION

Our T-score normal values for the lumbar spine (L2-L4) should be more reliable for spine-specific risk assessment than some non-representative normal ranges, and should be evaluated for that purpose in Europe. If T-scores are to be used to compare individual data with ranges seen in normal young subjects of the same nationality, it may be necessary to adjust femoral NHANES III-based T-scores by adding (or subtracting) a country-specific adjustment factor. In risk assessment it is probably sufficient to use NHANES III-based hip T-scores, as supplied for the hip by densitometer manufacturers, interpreting them in light of recent international meta-analysis data on the relationship between BMD and fracture risk.

The cost effectiveness of bisphosphonates for the prevention and treatment of osteoporosis: a structured review of the literature

Osteoporotic fragility fractures constitute a significant public health concern. The lifetime risk of any osteoporotic fracture is very high (40-50% in women and 13-22% in men). Fractures are associated with significant mortality and morbidity and represent a substantial economic burden to society. Bisphosphonates (alendronate, etidronate, risedronate and ibandronate) are indicated for the treatment and prevention of osteoporosis but are costly compared with other treatments, such as vitamin D and calcium. Our search identified 23 studies evaluating the cost effectiveness of bisphosphonate therapy for the treatment and prevention of fragility fractures; these studies were from five geographical areas and employed a variety of comparators and assumptions. We identified 11 studies investigating bisphosphonates in women with low bone mineral density (BMD) [T-score >2.5 standard deviations {SDs} below normal {mean} peak values for young adults] and previous fractures, five studies investigating bisphosphonates in women with low BMD and no previous fracture, one study of bisphosphonates in women with osteopenia, five studies involving screening and two studies of bisphosphonates in special populations (women initiating corticosteroid treatment and men). In women with low BMD and previous fractures, bisphosphonate therapy was most cost effective in populations aged > or =70 years and was unlikely to be cost effective in populations aged < or =50 years. There was uncertainty concerning the cost effectiveness of bisphosphonates in such populations aged 60-69 years. In women with low BMD without previous fractures, treatment with alendronate or risedronate appeared to be cost effective across countries (UK, US, Denmark), but there was some uncertainty about the cost effectiveness of etidronate in patients in the highest age groups. Identifying risk factors for fractures through means such as spine radiographs to detect vertebral deformities improves the cost effectiveness of treatment. In women with osteopenia, alendronate therapy may be cost effective in women with a T-score of -2.4SD in the US. Screening for low BMD and treatment with alendronate or etidronate appears to be cost effective in postmenopausal women in general and in women with rheumatoid arthritis initiating corticosteroid therapy. Alendronate therapy without screening was also shown to be potentially cost effective in certain at-risk male populations, as well as in women initiating corticosteroid therapy after the age of 40 years. Decision makers in the US, UK and Sweden should consider funding the use of bisphosphonates for the prevention and treatment of osteoporosis in women aged >70 years, particularly if they have other risk factors for fracture. Further studies are required to make more definitive conclusions in other countries and patient populations. Screening strategies for low BMD followed by bisphosphonate treatment should also be considered in the general female population aged >65 years in the UK and US and in patients with rheumatoid arthritis initiating corticosteroid therapy.