Guías de práctica clínica en la osteoporosis posmenopáusica, glucocorticoidea y del varón. Sociedad Española de Investigación Ósea y del Metabolismo Mineral

Incidence, morbidity and mortality of hip fractures over a period of 20 years in a health area of Southern Spain

OBJECTIVE

To evaluate the incidence of osteoporotic hip fracture in the Macarena Health Area (Seville).

SETTING AND PARTICIPANTS

This was a prospective observational study that collected all osteoporotic hip fractures that occurred between March 2013 and February 2014 at the Clinical Unit of Traumatology and Orthopaedics. All cases collected during the first 6 months of the study were followed for 1 year after the occurrence of the event.

OUTCOME MEASURES

We evaluated the incidence of osteoporotic hip fractures in the Macarena Health Area (Seville) from 1 March 2013 to 28 February 2014, and we compared the incidence with that in 2 previous studies carried out with the same methodology in 1994 and 2006. Furthermore, we calculated the morbidity and degree of disability 1 year after the fracture occurred and determined mortality and the associated factors.

RESULTS

The overall incidence was 228 per 100 000 individuals/year (95% CI 204.5 to 251.6), and the incidence was higher in women than in men. In women, the incidence rate decreased in all age groups over time, while in men, the incidence rate increased. The mortality rate 1 year after the episode was 27.2%. The factors associated with overall mortality were a body mass index below 25 kg/m², renal failure and low plasma proteins.

CONCLUSIONS

Our results show a high incidence of osteoporotic hip fracture that is increasing in men, and in men it is associated with a higher mortality than in women. There is room to improve the modifiable factors associated with mortality and the available rehabilitation interventions to reduce the disability associated with these fractures.

Osteoporosis and Psoriasis

Psoriasis is a chronic inflammatory disease associated with multiple comorbidities, particularly in patients with arthritis or more severe forms of the disease. The link between all these comorbidities is probably systemic inflammation. Several recent studies have indicated that patients with psoriasis may be at an increased risk of pathologic fractures and osteoporosis. Current guidelines on comorbidities in psoriasis do not recommend assessment of bone health. In this article, we review the available evidence on the association between psoriasis and osteoporosis. We first examine the concept of osteoporosis and the role of vitaminD in bone health and then propose an algorithm for managing and treating this condition in patients with psoriasis.

Treatments for post-menopausal osteoporotic women, what's new? How can we manage long-term treatment?

Since the mid-1980s, postmenopausal osteoporosis (PMO) has been considered a serious public health concern because of the associated fractures. Pharmacological therapies that effectively reduce the number of fractures by improving bone mass have been and are being developed continuously. Most current agents inhibit bone loss by reducing bone resorption, but emerging therapies may increase bone mass by stimulating bone formation. Furthermore, nowadays, the most representative pharmaceuticals have been prescribed long enough to include the reporting of some adverse effects. This review discusses osteoporotic drugs that are approved or are under investigation for the treatment of post-menopausal women (PMW), paying particular attention to long-term treatments.

Osteonecrose mandibular relacionada com bifosfonatos orais em paciente idosa polimedicada

A polifarmácia define-se como o consumo de cinco ou mais fármacos simultâneos durante um período de tempo determinado e é cada vez mais frequente em pessoas maiores de 65 anos. A osteoporose é a alteração metabólica óssea mais frequente nos países ocidentais e o segundo problema sanitário no mundo, depois das doenças cardiovasculares. Sua maior complicação é a fratura por fragilidade, afetando mais mulheres que homens. A prevenção de fraturas por osteoporose é feita com diversos tipos de remédios e os mais usados são os bifosfonatos. Estes são fármacos com amplo uso em Atenção Primária, principalmente para osteoporose pós-menopáusica. Apesar de serem bem tolerados, não estão isentos de efeitos secundários, sendo um dos mais graves a osteonecrose mandibular, como ocorre no caso exposto neste trabalho. Por este e outros motivos, sempre é importante ponderar risco-benefício de forma individualizada antes de começar qualquer tratamento e, principalmente, quando se trata a de pacientes polimedicados.

Prescription of alendronate and risedronate in men: off-label use in a health area

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.

[Orthogeriatric activity in public hospitals of Castilla y León: description and review of the literature]

The benefits of the collaboration between orthopaedics and geriatrics in the management and care of elderly patients admitted with hip fracture have been widely demonstrated. A questionnaire was sent to all hospital geriatricians of Castilla y León in order to determine the characteristics this collaboration between orthopaedics and geriatrics in the public hospitals of Castilla y León. They were asked about the type of collaboration with orthopaedics in the care of the elderly patient admitted with hip fracture and details of the treatment of the complications. Most of the hospitals maintain a high level of orthogeriatric collaboration with geriatricians, and the geriatrician attends to most of the medical complications of these patients. The average hospital stay is 10 days, with a surgical delay of 3 days. Management of the most frequent clinical problems in hospitals of Castilla y León are detailed in this article, comparing them with the latest articles and current recommendations from clinical practice guides.

Diabetes and osteoporosis: Action of gastrointestinal hormones on the bone

A 62-year-old woman consulted for evaluation of treatment for her type 2 diabetes diagnosed four years ago. He had been received treatment with metformin 850mg twice, with no chronic associated complications. She had hypertension and dyslipidemia. She was being treated with candesartan/hydrochlorothiazide 32/12.5mg and atorvastatin 40mg. Her weight was 92kg and height 162cm (BMI, 35.1kg/m(2)). The last analysis showed fasting glucose 168mg/dl and glycated hemoglobin 7.5%, Microalbuminuria was negative. Blood pressure and lipid profile were within the therapeutic range. Two years ago she suffered a nontraumatic Colle's fracture in her left arm for which she was taking a daily calcium and vitamin D supplement and weekly alendronate. In summary, this is an obese female patient with type 2 diabetes mellitus and inadequate metabolic control, She also has a history of fragility fracture. How should this patient be evaluated and treated?

[Calcium supplementation and the possible increase in cardiovascular risk]

The primary goal of osteoporosis treatment is to prevent the occurrence of fragility fractures, and thereby reduce morbidity and mortality. Among the various approaches to the treatment of this disease include ensuring proper calcium intake and to obtain adequate levels of vitamin D. Virtually all clinical trials with drugs used to treat osteoporosis systematically include calcium and vitamin D supplements. In light of the recent publication of clinical trials and meta-analyses, a possible increase in cardiovascular risk, particularly in the form of a myocrdial infarction, is hypothesised in patients taking calcium supplements. However, data published to date are inconclusive. Until the development of new scientific evidence, it seems reasonable to recommend, whenever practicable and individualized for each patient, increasing calcium intake with food and reserve supplements for patients with very low calcium intake in the diet. It would also be advisable for the administration of total daily dose to be fractionated throughout the day and with meals, and to obtain appropriate levels of vitamin D (25-hydroxycholecalciferol or calcidiol), along with the basic treatment for osteoporosis that is decided to be prescribed to patients.

[Identification of clinical features and laboratory abnormalities associated with the development of vertebral fractures in women with postmenopausal osteoporosis]

BACKGROUND AND OBJECTIVE

Vertebral fractures (VF) are a major risk factor for the development of further fractures. Therefore, it is important to identify clinical risk factors and laboratory abnormalities related to VF. We aimed to analyse clinical and biochemical alterations related to the presence of radiological VF in postmenopausal women with osteoporosis.

PATIENTS AND METHODS

Two-hundred and four postmenopausal women with osteoporosis (aged 64,9 [10] years) who were referred to an outpatient Rheumatology Unit were prospectively included. Bone mineral density (BMD), spine X-ray, and laboratory tests were performed in all participants before treatment.

RESULTS

Twenty-eight per cent of patients had VF. Comparing women with and without VF, those with fractures were older (71.9 [10] vs 61.8 [8,6], P<.001), had lower stature (152 [7.2] vs 155 [6.2], P=.01), lower total hip T-score values (-2.2 [0,9] vs -1.9 [0.8], P=.041), higher prevalence of non-VF (38 vs 30%, P=.04) and a higher prevalence of low serum 25(OH)D levels (69 vs 53%, P<.05). In logistic regression analysis, age and BMD at the total hip were independent predictors of VF. Patients over 65 presented a higher frequency of VF (47 vs 12%, P<.0001). In addition, a T-score lower than -2,5 at the total hip was associated with an increased risk of VF (OR 2.5; 95% CI 1.2-4.9).

CONCLUSIONS

Over the age of 65 nearly half of the postmenopausal women with osteoporosis have VF and a higher prevalence of low 25(OH)D serum measurements. Spinal X-ray and 25(OH)D serum measurements are especially indicated in this group of women since it influences the therapeutic approach.

Identifying and managing patients at high risk for fractures: conclusions from the second Spanish multidisciplinary forum-parathyroid hormone use in osteoporotic patients at high risk for fractures

Purpose

The Second Multidisciplinary Forum: Parathyroid Hormone (PTH) Use in Osteoporotic Patients at High Risk for Fractures (HRF) was conducted to identify specific findings that would be helpful for defining high-risk status and guiding the use of parathyroid hormone 1–84 (PTH1-84) as an anabolic therapy in daily clinical practice. This article summarizes the conclusions from the meeting.

Materials and Methods

Based on three typical case records, and the final conclusions from the first Forum (held in 2010), several questions were posed regarding daily clinical practice definitions of HRF and use of PTH1-84, through a series of 19 meetings throughout Spain. The main discussion topics and agreed conclusions were collected by meeting coordinators and shared at a meeting held in May 2011. After extensive discussions, which also included other organizational and educational matters, some newly agreed conclusions were reached.

Results

The consensus was that an HRF patient is usually thought of as being elderly (aged >70 years), with a very low bone mass or a prevalent fracture, and some other associated risk factors. High-risk groups who were identified included patients with neurologic diseases, institutionalized individuals, and patients receiving long-term steroid therapy. PTH1-84 was considered a safe and effective drug, having added value because of its analgesic effect and good level of patient adherence. Opportunities for improved PTH1-84 use were identified, such as better patient selection and follow-up based on localization and specialty. Some improvement opportunities were also detected in organizational and educational areas.

Conclusion

The Forum identified differences between clinical recommendations and daily clinical practice. Some elements, involving both organizational and educational areas that could help to reduce such discrepancies, are described.

A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis

This paper provides a framework for the development of national guidelines for the management of glucocorticoid-induced osteoporosis in men and women aged 18 years and over in whom oral glucocorticoid therapy is considered for 3 months or longer.

INTRODUCTION

The need for updated guidelines for Europe and other parts of the world was recognised by the International Osteoporosis Foundation and the European Calcified Tissue Society, which set up a joint Guideline Working Group at the end of 2010.

METHODS AND RESULTS

The epidemiology of GIO is reviewed. Assessment of risk used a fracture probability-based approach, and intervention thresholds were based on 10-year probabilities using FRAX. The efficacy of intervention was assessed by a systematic review.

CONCLUSIONS

Guidance for glucocorticoid-induced osteoporosis is updated in the light of new treatments and methods of assessment. National guidelines derived from this resource need to be tailored within the national healthcare framework of each country.

[Initial treatment trends in patient with osteoporosis: use of antiresorptive agents and pharmacologic supplements (calcium and vitamin D) in clinical practice]

OBJECTIVE

To describe the percentage of prescription of pharmacologic supplements in patients starting antiresorptive treatment (ART) for osteoporosis by specialists.

DESIGN

Cross-sectional, naturalistic, multicenter study with retrospective data collection.

PATIENTS AND METHODS

88 Spanish primary care (PC) physicians participated as well as those from Bone Metabolism Unit / Rheumatology and Gynecology units. Patients were females with osteoporosis who started ART in the 12 to 36 months prior to the visit.

MAIN OUTCOMES

General clinical variables and those related to osteoporosis treatment (both ART and pharmacologic supplements) and an opinion survey on pharmacologic supplements.

RESULTS

480 patients were included. Mean age (SD) was 65.8 (9.2) years. Pharmacologic supplements were prescribed in 69.6% of patients and were more frequent in patients treated in Bone Metabolism/Rheumatology Units (89.1%) than patients treated by PC (60.3%) and Gynecology (55.6%). In the physician survey, 72% of the Bone Metabolism / Rheumatology Unit physicians responded that the Vitamin D supplements were necessary for treatment of osteoporosis vs. 38.5% of PC physicians (p=0.058).

CONCLUSIONS

The use of pharmacologic supplements in the onset of treatment with ART represents more than 60% of the sample, although differences were seen between specialists, with a greater percentage of patients with supplements in the Bone Metabolism/Rheumatology Units than in PC and Gynecology, despite guidelines primarily recommend the use of pharmacologic supplements in these patients.

[Risk factors for fragility fractures in a cohort of Spanish women]

INTRODUCTION

Fragility fractures are an important public health issue. The aim of this study was to analyze the association of the main osteoporotic risk factors related to fragility fracture in a cohort of women with an indication of bone densitometry (BD).

METHODS

A retrospective cohort was followed-up until a fragile fracture occurred, in a population of women aged 40 to 90 years with a first visit for BD between January 1992 and February 2008. We calculated the incidence rate of fracture per 1000 women-years of follow-up, and the hazard ratio (HR) of fragile fracture using a Cox regression model.

RESULTS

A total of 49,735 women were studied. The average age of participants was 57.8 years (SD: 8.5). Of these, 3631 women (7.1%) reported a new fragility fracture in post-baseline visits. Risk factors with higher adjusted HR were age ≥ 75 years compared with age < 55 years (HR: 3.8; 95% CI: 3.3-4.4) and having a BC result evaluated as osteoporosis compared to normal (HR: 2.0; 95% CI: 1.8-2.2). A personal history of humerus, hip or vertebral fractures had an adjusted HR of 1.2 (95% CI: 1.1-1.3).

CONCLUSIONS

The main risk factors for fragility fracture were advanced age, BD result and a personal history of fracture, although 74% of fractures were detected with a bone mineral density classified as normal or osteopenia. Other relevant factors were rheumatoid arthritis or having received prolonged corticosteroid therapy.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Management of the patient with a high risk of fracture in clinical practice. Results from a survey of 174 Spanish Rheumatologists (OSTEOPAR project)]

OBJECTIVE

To collect information about diagnosis, classification and treatment of patients at high risk of fracture in the rheumatologist's practice.

MATERIAL AND METHODS

A survey was conducted among Spanish rheumatologists. The survey was aimed at gathering data on the physician's healthcare activity, the osteoporosis (OP) and fracture risk factors considered as most relevant, the diagnostic used tests and the treatment indication according to the presence of different risk factors.

RESULTS

99.5% of rheumatologists felt that there is a group of patients with OP at high risk of fracture. Previous fracture was considered the most important risk factor, particularly in case of multiple fractures, severe fractures, hip fracture, or that occurred during treatment. Glucocorticoid treatment, older age and low bone mineral density were considered, in this order, other important risk factors. The number of vertebral fractures was considered the most relevant radiological data, followed by the fracture's chronology and severity. Most of the respondents selected teriparatide as the first treatment option in high-risk patients.

CONCLUSIONS

The definition of OP patient with high risk of fracture is not uniform in daily practice, although the majority of rheumatologists considered that having a previous fracture is the most important risk factor, followed by glucocorticoid treatment, older age and low BMD. Anabolic treatment was the approach most commonly used in OP patients with high risk of fracture.

Premenopausal osteoporosis: how to treat?

There is no agreement in defining osteoporosis in premenopausal women and diagnosis must be done carefully and not based on densitometric parameters. One must take into account the presence of other risk factors and history of fragility fractures, diseases or drugs that cause bone loss. Over 50% of premenopausal women with osteoporosis will have a secondary cause, with the remainder diagnosed with idiopathic osteoporosis. Therapeutic considerations are limited by a few studies in this group of patients, especially in regard to the risk of fractures. On the other hand, the FRAX index cannot be applied to premenopausal women. This article will review the measures to apply depending on the type of premenopausal osteoporosis, based on current scientific evidence.

[Vitamin D and fractures in the elderly]

Osteoporosis and the subsequent fractures caused by this are a source of morbidity and mortality in the elderly population. It is also often the start of the cascade that culminates in frailty and dependence. Vitamin D has a direct relationship with the appearance of osteoporosis and with the risk of fractures. Receptors of this vitamin have also recently been described in other organs and systems of the body that are associated with muscle strength, cancer and overall mortality. Deficiency of this vitamin in the elderly population in Spain is very prevalent, both in the community and the hospitalised elderly. The diagnosis and treatment are straightforward and cheap. Its efficacy in the prevention of osteoporosis and in the appearance of fractures is perfectly demonstrated. In this review, we will look at the physiology and actions of this vitamin, as well as the principal studies that have demonstrated its effectiveness in the elderly population.

[Usefulness of FRAX tool for the management of osteoporosis in the Spanish female population]

BACKGROUND AND OBJECTIVE

Osteoporotic fractures involve a significant consumption of health resources. Bone densitometry has been essential in the management of osteoporosis. However, for fracture absolute risk prediction, other important clinical risk factors are also important. WHO published a risk estimation tool (FRAX), and the National Osteoporosis Guideline Group (NOGG) reported thresholds for densitometry assessment based on cost-effectivity criteria. Our goal is to determine the diagnostic predictive validity of FRAX in our population, and to assess how its use (according to NOGG guidelines) would modify the current number of referrals to DXA scan in our health system.

SUBJECTS AND METHODS

Diagnostic validation study in a consecutive sample of 1,650 women, 50 to 90 years old, under no treatment with anti-resortives, from the FRIDEX cohort. DXA and a questionnaire regarding risk factors were performed. ROC curve and area under the curve (AUC) were used to assess FRAX's diagnostic validity for femoral neck osteoporosis (FNOP). Risk of fracture was calculated using FRAX pre and postDXA, and women were classified according to their risk, following NOGG recommendations.

RESULTS

FRAX's ROC AUC for FNOP was 0.812 for major fracture and 0.832 for hip fracture. Using FRAX according to NOGG would result in performing only 25.2% of the current tests. If we added previous fracture antecedent to the algorithm, 49.4% of the tests performed would be advised.

CONCLUSIONS

The use of NOGG thresholds applied to FRAX would reduce about 50% the current number of referrals to DXA scan in our population. FRAX has a good diagnostic validity for FNOP.

Strontium ranelate: a review of its use in the treatment of postmenopausal osteoporosis

This is a review of the pharmacology of strontium ranelate (Protelos, Protos, Protaxos, Bivalos, Osseor), and its efficacy and tolerability in the treatment of patients with postmenopausal osteoporosis. Strontium ranelate is a divalent strontium salt of ranelic acid that is capable of increasing bone formation and reducing bone resorption, thereby uncoupling and rebalancing bone turnover in favour of bone formation. The drug is effective in reducing the risk of fractures, including both vertebral and nonvertebral fractures, in patients with postmenopausal osteoporosis, according to data from two large, double-blind, placebo-controlled, multicentre trials of 5 years' duration, and reduced the risk of hip fracture in high-risk patients in a post hoc analysis of one trial. Moreover, data from patients who continued to receive the drug during the 3-year extension phases of these trials indicate that strontium ranelate continues to provide protection against new vertebral fractures and nonvertebral fractures for up to 8 years of therapy. It also improves bone mineral density at numerous sites and both increases markers of bone formation and decreases markers of bone resorption. Strontium ranelate is administered orally as a suspension and is generally well tolerated. The nature of adverse events was generally similar regardless of treatment duration in clinical trials, with the most commonly reported being nausea and diarrhoea over 5 years of treatment, and memory loss and diarrhoea during longer-term treatment. Although an increased risk of venous thromboembolism was associated with strontium ranelate relative to placebo over 5 years of treatment in a pooled analysis of clinical trials, postmarketing data have not confirmed this finding. Overall, the clinical data available suggest that strontium ranelate is an effective and generally well tolerated option for the first-line treatment of postmenopausal osteoporosis.

[Clinical characteristics of patients under treatment for osteoporosis in a Primary Care Centre. Who do we treat?]

OBJECTIVES

To find out the clinical and demographic features of patients in treatment for osteoporosis, look for risk factors for osteoporosis and bone fractures, and assess whether treatment is indicated.

DESIGN

Descriptive study of a series of cases.

LOCATION

Primary Care Centre, Madrid.

PARTICIPANTS

216 patients on treatment for osteoporosis during 2007.

PRINCIPAL MEASURES

Sociodemographic variables, osteoporosis risk factors, risk of falling, prescription and treatment related information. To evaluate if treatment is indicated we have used principal medical guidelines.

RESULTS

Most of our patients were Caucasian women with a mean age of 66.14 years. A total of 39.5% had suffered an osteoporotic fracture and 16.12% had family history of osteoporotic fracture. The majority of our registers,73.15%, do not report information on Dual-Energy X-ray Absorptiometry (DEXA), and 73.13% do not make any reference to bone mineral density. Risk factors are not recorded in most of the clinical histories. Only 51.85% of the treatments were well indicated, and 44% of them began at a primary health care centre.

CONCLUSIONS

Nearly 50% of treatments are not well indicated and a high percentage of our clinical histories do not record risk factors correctly. We should improve our clinical histories, as we are responsible for identifying, studying, evaluating, treating and controlling the progress of osteoporosis.