Secondary Osteoporosis: Are We Recognizing It?

Laboratory evaluation of secondary causes of bone loss in Veterans with spinal cord injury and disorders

An electronic health record (eHR) review of Veterans with a spinal cord injury and disorder (SCI/D) was conducted to understand the extent to which Veterans Affairs (VA) providers pursue workups for secondary causes of osteoporosis in this population. Laboratory tests for secondary causes were ordered in only one-third of Veterans, with secondary causes identified in two-thirds of those tested, most frequently, hypogonadism and hypovitaminosis D.

PURPOSE

To identify workups for secondary causes of osteoporosis in SCI/D and the extent to which subspecialty consultations are sought.

METHODS

A total of 3018 prescriptions for an osteoporosis medication (bisphosphonate, calcitonin, denosumab, raloxifene, teriparatide) among 2675 Veterans were identified in fiscal years 2005-2015 from VA administrative databases. Approximately 10% of these prescriptions were selected for eHR review.

RESULTS

eHR records of 187 Veterans with a SCI/D who had received pharmacological treatment for osteoporosis were reviewed. Workups for secondary causes of osteoporosis were performed in 31.5% of Veterans (n = 59) with approximately 64.4% of those tested (n = 38) having at least one abnormality. Hypogonadism (52.0% of those tested) and hypovitaminosis D (50.0% of those tested) were the most common secondary causes of osteoporosis identified in this population. Approximately 10% of primary care and SCI providers consulted subspecialists for further evaluation and treatment of osteoporosis. Endocrinologists more frequently performed a workup for secondary causes of osteoporosis compared to other provider specialties.

CONCLUSIONS

Screening for secondary causes of osteoporosis, particularly for hypogonadism and hypovitaminosis D, should be considered in patients with a SCI/D.

Chronic obstructive pulmonary disease and low bone mass: A case-control study

Background and Objective:

Low bone mass (osteopenia and osteoporosis) is one of the effects associated with chronic obstructive pulmonary disease (COPD). There is very little data from Saudi Arabia on COPD and low bone mass. This retrospective study was done to assess the prevalence of osteoporosis and osteopenia in COPD patients attending King Fahd Hospital of the University (KFHU), Alkhobar.

Patients and Methods:

After obtaining the ethical approval from the research committee, all patients seen between at the King Fahd Hospital of the University between January 2010 and December 2012 were included. The inclusion criteria included a follow up of a minimum 2 years, and the Medical Records should have the details of forced expiratory volume in one second (FEV₁), blood bone profile and bone biomarkers and dual-energy X-ray absorptiometry (DEXA) scan. Patients were labeled as osteopenia if the T score was -<1 to <-2.5 and osteoporosis of <-2.5 as per the WHO definition of osteopenia and osteoporosis.

Results:

Seventy-three patients were being followed in the clinics and 49 patients satisfied the inclusion criteria. The average age was 60.6 ± 10.47 years; males were 43 and females 6. Three (6.1%) were normal and the remaining 46 (93.9%) were with low bone mass. Thirty-two (65.3%) were osteoporotic and 14 (28.57%) were osteopenic. The average duration of COPD was 4.5 ± 6.2 years. Majority (n = 36, 73.4%) of patients were in the Global Initiative for COPD (GOLD) class II and III. FEV₁ was significantly lower in the patients with low bone mass 1.66 ± 0.60 versus 3.61 ± 0.58 (P < 0.001).

Conclusions:

Our study shows that over 90% of Saudi Arabian patients with COPD suffer from osteopenia and osteoporosis and unfortunately they remain under-diagnosed and undertreated.

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.

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

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Markers of autoimmune liver diseases in postmenopausal women with osteoporosis

INTRODUCTION

Osteoporosis is a common complication of chronic liver diseases. However, there is limited information about autoimmune liver diseases as a factor of secondary osteoporosis. Therefore, we aimed to investigate the autoantibodies of autoimmune liver diseases in patients with osteoporosis.

METHODS

One hundred fifty female patients with postmenopausal osteoporosis were included. Bone mineral density was measured by dual energy X-ray absorptiometry. We analysized autoantibodies including antinuclear antibodies, liver membrane antibodies, anti-liver/kidney microsomal autoantibodies1, liver-specific protein, antismooth muscle antibodies, and anti-mitochondrial antibodies by indirect immunofluorescence. Serum was assayed for the levels of aminotransferases.

RESULTS

The mean age of the patients was 63,13 ± 8,6 years. The mean values of L1-L4 T-scores and femur total T-scores were -3,08 ± 0,58 and -1,53 ± 0,81, respectively. Among the 150 patients with osteoporosis, 14 (9.3%) were antinuclear antibodies, four (2.7%) were liver membrane antibodies, three (2.0%) were anti-liver/kidney microsomal autoantibodies1, and two (1.3%) were liver-specific protein positive. None of the patients had anti-mitochondrial antibodies or smooth muscle antibodies positivity. The mean values of levels of aminotransferases were within normal range.

CONCLUSIONS

The presence of liver membrane antibodies, liver-specific protein, and anti-liver/kidney microsomal autoantibodies1 has permitted us to see that there may be some suspicious clues of autoimmune liver diseases in patients with osteoporosis as a secondary risk factor. On the other hand, there is a need for comprehensive studies with a larger sample size and studies designed to compare the results with a normal population to understand the clinical importance of our findings.

Repeat dual-energy X-ray absorptiometry (DXA) resulting from reminder letters for women with a baseline abnormal DXA

The objective was to assess the effects of reminder letters on women returning for repeat bone density. We queried our clinical data repository to identify all women undergoing dual-energy X-ray absorptiometry (DXA) during the entire 2003 calendar year. Women with abnormal DXAs were entered into a database for reminder letters. The electronic medical record was then reviewed for the presence of the reminder letter and whether any repeat DXA scan was done. Approximately half of the women returned for repeat DXA of this group, approximately one-third were improved, one-third deteriorated, and the remaining were unchanged. We suggest a clinical benchmark of a minimum of 50% of women with abnormal bone density returning for repeat DXA on the same machine at a DXA imaging center should be a quality improvement goal. Further research into exploring why patients do not return for serial DXA and the impact of reminder letters on improving treatment outcomes should be conducted.