Intermittent cyclical etidronate in the prevention of corticosteroid-induced bone loss

Seventeen-Year National Pain Prevalence Trends Among U.S. Military Veterans

Importance

U.S. military veterans experience higher pain prevalence and severity than nonveterans. However, it is unclear how these differences have changed over time. Previous studies are limited to veterans receiving care from the Veterans Health Administration.

Objective

To characterize pain prevalence trends in the overall population of U.S. veterans compared to nonveterans, using nationally-representative data.

Design

Repeated cross-sectional study. Data: National Health Interview Survey, 2002-2018. Analysis: January 2023.

Setting

Population-based survey of noninstitutionalized U.S. adults.

Participants

Across the 17-year period, mean annual weighted population was 229.7 million adults (unweighted sample total: n=506,639; unweighted sample annual mean: n=29,802).

Exposure

Veteran status.

Main Outcomes

Crude and demographics-adjusted pain prevalence trend differences between veterans and nonveterans across five pain variables (severe headache or migraine, facial pain, neck pain, low back pain, and joint pain) and two composite variables (any pain [≥1 prevalent pain] and multiple pains [≥2 prevalent pains]).

Results

Weighted proportion of veterans varied from 11.48% in 2002 (highest) to 8.41% in 2017 (lowest). Across the study period, crude prevalence was generally similar or higher among veterans than nonveterans for all pain variables except for severe headache or migraine and facial pain. When equalizing age, sex, race, and ethnicity, pain prevalence among veterans remained similar or higher than nonveterans for all pain variables. From 2002 to 2018 there was an absolute increase (95% CI) in pain prevalence among veterans (severe headache or migraine: 2.0% [1.6% to 2.4%]; facial pain: 1.9% [1.4% to 2.4%]; neck pain: 4.7% [4.1% to 5.2%]; joint pain: 11.4% [10.8% to 11.9%]; low back pain: 10.3% [9.5% to 11.1%]; any pain: 10.0% [9.6% to 10.4%]; and multiple pains: 9.9% [9.2% to 10.6%]. Crude and adjusted analyses indicated prevalence of all pain variables increased more among veterans than nonveterans from 2002 to 2018.

Conclusion and Relevance

Veterans had similar or higher adjusted prevalence and higher rates of increase over time for all pain variables compared to nonveterans. Continued pain prevalence increase among veterans may impact healthcare utilization (within and outside of the VHA), underscoring the need for improved pain prevention and care programs for these individuals with disproportionate pain burden.

Hip and knee replacement as a proxy measure for lower limb osteoarthritis in Scottish military veterans

INTRODUCTION

Physical activity is an important component of military training. Although injuries and musculoskeletal disorders are the most common cause of medical retirement from the Armed Forces, the long-term risk of lower limb osteoarthritis in veterans is unknown. We used data on hip and knee replacement in Scottish military veterans as a proxy measure.

METHODS

Retrospective cohort study of 78 000 veterans born between 1945 and 1995 and a comparison group of 253 000 non-veterans, matched for age, sex and area of residence, followed up for up to 37 years, using survival analysis to examine the risk of hip and knee replacement.

RESULTS

Veterans were significantly less likely to undergo hip replacement than non-veterans, Cox proportional HR 0.87, 95% CI 0.80 to 0.95, p<0.001. There was no significant difference between veterans and non-veterans in respect of knee replacement, HR 1.02, 95% CI 0.94 to 1.11, p=0.643, and there was no difference in the ages at which veterans and non-veterans underwent joint replacement. People who had served for longest in the military had similar risk to those with the shortest service.

CONCLUSIONS

Based on the likelihood of undergoing joint replacement surgery in later life, we found no evidence of a positive association between military service and an increased risk of lower limb osteoarthritis.

Bisphosphonates in dentistry: Historical perspectives, adverse effects, and novel applications

Studies of the potential role of bisphosphonates in dentistry date back to physical chemical research in the 1960s, and the genesis of the discovery of bisphosphonate pharmacology in part can be linked to some of this work. Since that time, parallel research on the effects of bisphosphonates on bone metabolism continued, while efforts in the dental field included studies of bisphosphonate effects on dental calculus, caries, and alveolar bone loss. While some utility of this drug class in the dental field was identified, leading to their experimental use in various dentrifice formulations and in some dental applications clinically, adverse effects of bisphosphonates in the jaws have also received attention. Most recently, certain bisphosphonates, particularly those with strong bone targeting properties, but limited biochemical effects (low potency bisphosphonates), are being studied as a local remedy for the concerns of adverse effects associated with other more potent members of this drug class. Additionally, low potency bisphosphonate analogs are under study as vectors to target active drugs to the mineral surfaces of the jawbones. These latter efforts have been devised for the prevention and treatment of oral problems, such as infections associated with oral surgery and implants. Advances in the utility and mechanistic understanding of the bisphosphonate class may enable additional oral therapeutic options for the management of multiple aspects of dental health.

Assessment of Risk Factors for Bone Disease in Renal Transplant Recipients

Background

Renal allograft recipients are at increased risk of osteoporosis and fractures because of their multiple risk factors for reduced bone mineral density (BMD).

Objective

To retrospectively assess the risk factors that may predispose renal transplant recipients to reduced BMD.

Methods

Thirty-one consecutive renal allograft recipients who had their hip and spine BMD measured by dual energy X-ray absorptiometry were evaluated. Individual patient medical records were reviewed for risk factors including demographics, laboratory parameters, glucocorticoid use, medical history, physical activity, and gonadal status. Fisher's exact test and Kruskal-Wallis chi-square approximations were used to compare BMD groups (p < 0.05). Analysis of variance with a Bonferroni adjustment was used to compare differences between BMD groups (p = 0.01) Linear regression analysis was used to correlate BMD with clinical parameters.

Results

A trend for younger patients (mean 43 y) to have osteoporosis and older patients (mean 54 y) to be osteopenic (p = 0.056) was seen. Higher body weight (p = 0.003) and higher creatinine clearance (p = 0.008) were associated with normal BMD results. Linear regression analysis showed a strong correlation between hip and spine BMD and creatinine clearance. Our data failed to show a statistical relationship between cumulative glucocorticoid dose or daily doses of greater than 7.5 mg and lower BMD. Neither male gender nor premenopausal status seemed to provide protection from reduced BMD.

Conclusions

These results suggest that all renal allograft recipients, regardless of age, gender, or hormonal status, may be at risk for the development of osteoporosis.

Physical and Mental Health Consequences of War-related Stressors Among Older Adults: An Analysis of Posttraumatic Stress Disorder and Arthritis in Northern Vietnamese War Survivors

Objectives

We examine the impacts of trauma exposures and family stressors associated with the Vietnam War on musculoskeletal health and posttraumatic stress disorder (PTSD) outcomes in elderly Vietnamese who were widely impacted by the war as young adults. Noting that wars' impacts extend beyond male veterans in most survivor populations, we give attention to male and female war survivors placed in a variety of roles vis-a-vis the war.

Method

Utilizing data from the 2010 Vietnam Health and Aging Pilot Study (N = 405), we use logistic and Poisson regression models to estimate the effect of wartime trauma exposures and family stressors on disabling arthritis and PTSD symptoms in male and female northern Vietnamese adults aged 55 and older.

Results

The odds of experiencing recent PTSD symptoms are greater in respondents who report involvement in killing/causing severe injury and who observed war atrocities. In women, PTSD is positively correlated with war era child death and spousal separation. Arthritis also exhibits a significant, positive association with killing/causing severe injury.

Discussion

Our study provides insights into the burden of conflict upon health among populations of the global south that survived war and are now entering older adulthood. The pattern of results, indicating greatest suffering among those who inflicted or failed to prevent bodily harm or loss of life, is consistent with the concept of moral injury.

Association of Pain With Physical Function, Depressive Symptoms, Fatigue, and Sleep Quality Among Veteran and non-Veteran Postmenopausal Women

PURPOSE OF STUDY

To characterize the prevalence and longitudinal effects of pain in older Veteran and non-Veteran women.

DESIGN AND METHODS

Data on 144,956 participants in the Women's Health Initiative were analyzed. At baseline, Veteran status, pain severity, and pain interference with activity were assessed. Outcomes of physical function, depressive symptoms, fatigue, and sleep quality were reported at baseline by all study participants and longitudinally on two follow-up occasions (3 years and 13-18 years after baseline) in the observational study participants (n = 87,336).

RESULTS

At baseline, a total of 3,687 (2.5%) had a history of military service and 22,813 (15.8%) reported that pain limited their activity level moderately to extremely during the past 4 weeks. Prevalence of pain interference did not differ in Veterans and non-Veterans (16.8% and 15.7%, respectively; p= .09). At baseline, women with moderate-to-extreme pain interference had substantially worse physical function and greater symptoms of depression, fatigue, and insomnia than those with less pain (p < .001 for all comparisons), adjusting for several social, behavioral, and health related factors. There were no significant military service by pain interference interactions for any of the outcomes (p > .2), indicating that the effect of pain interference on outcomes at baseline did not vary between Veterans and non-Veterans. Moderate-to-extreme pain interference was associated with a greater rate of decline in physical function over time (p < .001) and higher incidence of limited physical functioning (p < .001), but these effects did not vary by Veteran status. Similar results were observed with pain severity as the exposure variable.

IMPLICATIONS

As the Veteran population ages and the number of women exposed to combat operations grows, there will be an increased need for health care services that address not only pain severity and interference but also other disabling comorbid symptoms.

Management of glucocorticoid-induced osteoporosis: clinical data in relation to disease demographics, bone mineral density and fracture risk

INTRODUCTION

Glucocorticoid-induced osteoporosis (GIOP) is the most common type of secondary osteoporosis. Patient selection and the treatment choice remain to be controversial. None of the proposed management guidelines are widely accepted. We evaluate the available clinical data, the efficacy of current medication and we propose an overall algorithm for managing GIOP.

AREAS COVERED

This article provides a critical review of in vivo and clinical evidence regarding GIOP and developing evidence-based algorithm of treatment. Data base used includes MEDLINE® (1950 to May 2014).

EXPERT OPINION

Patient-specific treatment is the gold standard of care. Glucocorticoid (GC)-treated patients must comply with a healthy lifestyle and receive 1000 mg of calcium and at least 800 mg of Vitamin D daily. Bisphosphonate (BP) therapy is the current standard of care for prevention and treatment of GIOP. Most of bisphosphonates demonstrated benefit in lumbar bone mineral density (BMD) and some in hip BMD. Alendronate, risedronate and zoledronate showed vertebral anti-fracture efficacy in postmenopausal women and men. Scarce data however when compared head to head with BP efficacy. In post-menopausal women, early antiresorptive BP treatment appears to be efficient and safe. In premenopausal women and patients at high risk of fracture receiving long-term GC therapy however, teriparitide may be advised alternatively.

Bisphosphonates for the prevention and treatment of osteoporosis in patients with rheumatic diseases: a systematic review and meta-analysis

Background

While bisphosphonates (BPs) are commonly used in clinical treatment for osteoporosis, their roles on osteoporosis treatment for rheumatic patients remain unclear. We performed a meta-analysis to evaluate the efficacy of BPs on fractures prevention and bone mass preserving in rheumatic patients.

Methodology/Principal Findings

We searched PubMed, EmBase, and the Cochrane Central Register of Controlled Trials for relevant literatures with a time limit of Jan. 6, 2012. All randomized clinical trials of BPs for adult rheumatic patients with a follow-up of 6 months or more were included. We calculated relative risks (RRs) for fractures and weighted mean difference (WMD) for percent change of bone mineral density (BMD). Twenty trials were included for analysis. The RR in rheumatic patients treated with BPs was 0.61 (95%CI [0.44, 0.83], P = 0.002) for vertebral fractures, and 0.49 (95%CI [0.23, 1.02], P = 0.06) for non-vertebral fractures. The WMD of BMD change in the lumbar spine was 3.72% (95%CI [2.72, 4.72], P<0.001) at 6 months, 3.67% (95%CI [2.84, 4.50], P<0.001) at 12 months, 3.64% (95%CI [2.59, 4.69], P<0.001) at 24 months, and 5.87% (95%CI [4.59, 7.15], P<0.001) at 36 months in patients using BPs, as compared with those treated with calcium, vitamin D or calcitonin. In subgroup analyses, rheumatic patients using BPs for osteoporosis prevention had greater WMD than those using BPs for treating osteoporosis at 6 months (4.53% vs. 2.73%, P = 0.05) and 12 months (4.93% vs. 2.91%, P = 0.01).

Conclusions/Significance

In both short-term and middle-term, BPs can preserve bone mass and reduce the incidence of vertebral fractures in rheumatic patients, mainly for those who have GC consumption. The efficacy of BPs is better when using BPs to prevent rather than to treat osteoporosis in rheumatic patients.

Differences in osteoarthritis self-management support intervention outcomes according to race and health literacy

We explored whether the effects of a telephone-based osteoarthritis (OA) self-management support intervention differed by race and health literacy. Participants included 515 veterans with hip and/or knee OA. Linear mixed models assessed differential effects of the intervention compared with health education (HE) and usual care (UC) on pain (Arthritis Impact Measurement Scales-2 [AIMS2] and Visual Analogue Scale), function (AIMS2 mobility and walking/bending), affect (AIMS2) and arthritis self-efficacy by: (i) race (white/non-white), (ii) health literacy (high/low) and (iii) race by health literacy. AIMS2 mobility improved more among non-whites than whites in the intervention compared with HE and UC (P = 0.02 and 0.008). AIMS2 pain improved more among participants with low than high literacy in the intervention compared with HE (P = 0.05). However, we found a differential effect of the intervention on AIMS2 pain compared with UC according to the combination of race and health literacy (P = 0.05); non-whites with low literacy in the intervention had the greatest improvement in pain. This telephone-based OA intervention may be particularly beneficial for patients with OA who are racial/ethnic minorities and have low health literacy. These results warrant further research designed specifically to assess whether this type of intervention can reduce OA disparities.

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.

Corticosteroid-induced osteoporosis: an update for dermatologists

Long-term corticosteroid treatment is the most common secondary cause of bone loss. Patients treated with long-term corticosteroid therapy may develop osteopenia or osteoporosis, and many have fractures. It is difficult to predict which corticosteroid-treated patients will develop significant skeletal complications because of variability in the underlying diseases treated with corticosteroids, and because of variation in corticosteroid dose over time. Corticosteroid therapy causes an alteration in the ratio between osteoprotegerin (OPG) and receptor activator of nuclear factor κ B (RANK) ligand (RANKL), which leads to early increased bone resorption for the first 3-6 months, with long-term treatment leading primarily to suppression of bone formation. Recently published recommendations advise the use of bisphosphonates or teriparatide in high-risk patients, depending on fracture risk assessed by bone mineral density testing. This article gives an update of current knowledge regarding the pathophysiology, clinical presentation and evaluation, and prevention and treatment of patients with corticosteroid-induced osteoporosis.

Discordance Between Self-report of Physician Diagnosis and Administrative Database Diagnosis of Arthritis and Its Predictors

Objective.

To study predictors of discordance between self-reported physician diagnosis and administrative database diagnosis of arthritis.

Methods.

A cohort of all veterans who utilized Veterans Integrated Service Network (VISN)-13 medical facilities were mailed a questionnaire that included patient self-report of physician diagnosis of arthritis and questions regarding demographics, functional limitation, and SF-36V (a validated version of the Medical Outcomes Study Short-Form 36). Kappa coefficient was used to assess the extent of agreement between self-report of physician diagnosis and administrative database definitions that incorporated International Classification of Diseases (ICD) codes and use of medications for arthritis. We identified predictors of overall discordance between self-report and administrative database diagnosis using multivariable logistic regression analyses.

Results.

Among 70,334 eligible veterans surveyed, 19,749 subjects had an ICD diagnosis of arthritis in the administrative database in the year prior to the survey; 34,440 answered the arthritis question and 18,464 self-reported a physician diagnosis of arthritis. Kappa coefficient showed slight to fair agreement of 0.19–0.32 between self-report and administrative database definitions of arthritis. We found significantly higher overall discordance among veterans with more comorbidities, greater age, worse functional status, lower use of outpatient and inpatient services, lower education level, and among single medical-site users.

Conclusion.

Low level of agreement between self-report and database diagnosis of arthritis and its significant association with patient demographic, clinical, and functional characteristics highlights the limitation of use of these strategies for identification of patients with arthritis in epidemiological studies.

Systematic review of trends in prophylaxis of corticosteroid-induced osteoporosis: the need for standard audit guidelines

Corticosteroid-induced osteoporosis (CIOP) is currently undertreated. Systematic review of the literature revealed that the percentage of patients treated adequately is dependent on study quality. Therefore, it remains unknown whether adherence to the guidelines is really so poor. Five major quality criteria provide the standard for future studies on this scope.

INTRODUCTION

It has recently been stated that the degree of prophylaxis of corticosteroid-induced osteoporosis (CIOP) is low and effort should be put into determining reasons for non-prescribing of preventive agents. The aim of this study was to identify: how many studies adequately audit the prevalent guideline; the longitudinal trends in prevention of CIOP; which patient groups appear to be most undertreated; and which intervention strategies are effective.

METHODS

We performed a comprehensive search of MEDLINE and systematically recorded the outcomes and quality of published studies, using five major criteria.

RESULTS

Twenty-four studies were included in the analysis. The quality of the included studies was poor (31%) or moderate (37%). There was a longitudinal increase in quality of the studies and percentage of prevention. Multivariable linear regression showed that the quality of the study was the only independent predictor of the prevention rate reported in the study.

CONCLUSIONS

The results show undertreatment of CIOP might be due to insufficient quality of the studies rather than poor practice or failure to recognise the right patients. Future interventions should comply with five major quality criteria, and a multifaceted approach is required in order to make an impact on the underprescribing of CIOP prophylaxis.

Etidronate: what is its place in treatment of primary osteoporosis and other demineralizing diseases today?

Bisphosphonate drugs are the major treatment options for primary and secondary osteoporosis and other demineralizing bone diseases. This class of drugs was presaged over a decade ago when etidronate disodium, the "mother compound" for modern-day bisphosphonates, was first used in the treatment of osteoporosis. The cyclic use of etidronate in therapy, which is known mainly to specialists in the field, is not approved in the United States. The drug does, however, have a worldwide reputation as a relatively inexpensive, efficacious, and highly tolerable treatment for osteoporosis. Many studies still describe its use for primary osteoporosis and some have described use in immobilization bone loss, periprosthetic bone loss, and even glucocorticoid-induced osteoporosis. This review highlights some of these uses.

Glucocorticosteroid-induced spinal osteoporosis: scientific update on pathophysiology and treatment

Glucocorticosteroid-induced spinal osteoporosis (GIOP) is the most frequent of all secondary types of osteoporosis. The understanding of the pathophysiology of glucocorticoid (GC) induced bone loss is of crucial importance for appropriate treatment and prevention of debilitating fractures that occur predominantly in the spine. GIOP results from depressed bone formation due to lower activity and higher death rate of osteoblasts on the one hand, and from increase bone resorption due to prolonged lifespan of osteoclasts on the other. In addition, calcium/phosphate metabolism may be disturbed through GC effects on gut, kidney, parathyroid glands and gonads. Therefore, therapeutic agents aim at restoring balanced bone cell activity by directly decreasing apoptosis rate of osteoblasts (e.g., cyclical parathyroid hormone) or by increasing apoptosis rate of osteoclasts (e.g., bisphosphonates). Other therapeutical efforts aim at maintaining/restoring calcium/phosphate homeostasis: improving intestinal calcium absorption (using calcium supplementation, vitamin D and derivates) and avoiding increased urinary calcium loss (using thiazides) prevent or counteract a secondary hyperparthyroidism. Bisphosphonates, particularly the aminobisphosphonates risedronate and alendronate, have been shown to protect patients on GCs from (further) bone loss to reduce vertebral fracture risk. Calcitonin may be of interest in situation where bisphosphonates are contraindicated or not applicable and in cases where acute pain due to vertebral fracture has to be manage. The intermittent administration of 1-34-parathormone may be an appealing treatment alternative, based on its documented anabolic effects on bone resulting from the reduction of osteoblastic apoptosis. Calcium and vitamin D should be a systematic adjunctive measure to any drug treatment for GIOP. Based on currently available evidence, fluoride, androgens, estrogens (opposed or unopposed) cannot be recommended for the prevention and treatment of GIOP. However, substitution of gonadal hormones may be indicated if GC-induced hypogonadism is present and leads to clinical symptoms. Data using the SERM raloxifene to treat or prevent GIOP are lacking, as are data using the promising bone anabolic agent strontium ranelate. Kyphoplasty performed in appropriately selected osteoporotic patients with painful vertebral fractures is a promising addition to current medical treatment.

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.

Glucocorticoid-Induced Osteoporosis: Mechanisms and Therapeutic Approach

GCs constitute a therapeutic class largely used in clinical medicine for the curative or supportive treatment of various conditions involving the intervention of numerous medical specialties. Beyond their favorable therapeutic effects, GCs almost invariably provoke bone loss and a rapid increase in bone fragility, with its host of fractures. Men and postmenopausal women constitute a preferential target for the bone complications of GCs. The premenopausal status is not, however, a shelter; bone loss also happens in young women who are on GCs. Exposure to GCs yields a fracture risk exceeding the risk conferred by a low BMD per se. Therefore, some reason exists to settle the BMD threshold for therapeutic intervention not at -2.5 T-scores but at -1.0 or -1.5 T-scores, even if no prospective randomized trial so far endorses that opinion. Nowadays, bisphosphonate therapy should be proposed to every patient at risk for fragility fracture, along with calcium and vitamin D supplementation. Studies of other therapeutic modalities (eg, promoters of bone formation) are in progress.

Evidence-based guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis: a consensus document of the Belgian Bone Club

Glucocorticoids (GCs) are frequently prescribed for various inflammatory and/or life-threatening conditions concerning many systems in the body. However, they can provoke many aftereffects, of which osteoporosis (OP) is one of the most crippling complications, with its host of fractures. The dramatic increase in bone fragility is mainly attributable to the GC-induced rapid bone loss in all skeletal compartments. We have reviewed the meta-analyses and randomized controlled studies reporting medical therapeutic interventions currently registered in Belgium for the management of GC-OP comparatively with a placebo. Based on this research, an expert meeting developed a consensus on the prevention and therapy of GC-OP. The pathophysiology of GC-OP is complex. Several factors, acting separately or synergistically, have been described. Their great number could help to understand the rapidity of bone loss and of bone fragility occurrence, indicating that a rapid therapeutic intervention should be implemented to avoid complications. All patients on GCs are threatened with OP, so the prevention and/or therapy of GC-OP should be considered not only for postmenopausal females, but also for osteopenic premenopausal females and for males put on a daily dose of at least 7.5 mg equivalent prednisolone that is expected to last at least 3 months. Non-pharmacological interventions, such as exercise and avoidance of tobacco and alcohol, should be recommended, even if their role is not definitely settled in GC-OP prevention. Supplemental calcium and vitamin D should be considered as the first-line therapy because of the decrease in intestinal calcium absorption provoked by GCs. They also could be considered either as isolated therapy in patients taking less than 7.5 mg prednisolone daily and/or for a predicted period shorter than 3 months or as adjuvant therapy to other more potent drugs. Hormone replacement therapy could be considered in young postmenopausal females on GC, such as in postmenopausal OP, or in men with low androgen levels. Calcitonin appears to have a protective effect on trabecular bone in GC-OP, just as in postmenopausal OP. There is an increasing body of evidence supporting the antifracture efficacy of bisphosphonates, notably alendronate and risedronate. Preventative and curative therapy of GC-OP should be maintained as long as the patient is on GC treatment and could be stopped after weaning from GC, because there is more than circumstantial evidence of some recovery of BMD when GCs are stopped. There is no indication in GC-OP for any combination of two antiresorptive agents (except for calcium and vitamin D) or for an antiresorptive and an anabolic agent. There is indeed no proof that the increased costs of combined treatments will translate into increased therapeutic efficacy.

In whom and how to prevent glucocorticoid-induced osteoporosis

Glucocorticoid use is widespread in medicine. While it is often life-saving, side-effects are well known. The most common side-effect is osteoporosis. Today we have therapies with proven efficacy for the prevention of vertebral fractures and bone loss. Consequently recognition of glucocorticoid-induced osteoporosis is extremely important given the availability of effective therapy.

The short-term effects of Eudragit-L-coated prednisolone metasulphobenzoate (Predocol) on bone formation and bone mineral density in acute ulcerative colitis

BACKGROUND

The aetiology of bone loss in ulcerative colitis is multifactorial, but corticosteroid treatment is an important risk factor. A novel formulation of Eudragit-L-coated prednisolone metasulphobenzoate (Predocol) has been developed, in order to deliver high mucosal levels of prednisolone within the colon but with little systemic absorption. The aim of this study was to investigate its efficacy, and short-term effects on bone formation and bone mineral density.

METHODS

In a 12-week longitudinal study 13 patients with active colitis were treated with a reducing dose of Predocol. Disease activity scores were recorded and the bone formation marker osteocalcin was measured before, during and after treatment, with hip and spine bone mineral density assessed at baseline and after treatment.

RESULTS

Eleven of the 13 patients completed the study. Compared with baseline, disease activity scores improved significantly after 4 weeks [difference in means, 6.9; 95% confidence interval (CI), 5.2, 8.7; P < 0.0001] and 12 weeks (difference in means, 5.7; 95% CI, 3.3, 8.2; P < 0.0001) of treatment. Osteocalcin did not fall compared with baseline [16.91 mg/l (95% CI, 12.70, 21.12)], after 4 weeks [13.67 mg/l (95% CI, 8.72, 18.60)] (difference in means, 3.25; 95% CI, 2.37, 8.87; P = 0.23) or 12 weeks [23.91 mg/l (95% CI, 16.10, 31.74)] (difference in means, 13.23; 95% CI, 2.45, 16.48; P = 0.13) of treatment. Similarly, bone mineral density at the hip [0.99 g/cm (95% CI, 0.90, 1.09)] did not change after 12 weeks of treatment [1.00 g/cm (95% CI, 0.89, 1.11)] (difference in means, 0.01; 95% CI, 0.25, 0.34; P = 0.74). Spine bone mineral density did not fall from pre-treatment levels [1.20 g/cm (95% CI, 1.11, 1.30)] after 12 weeks [1.19 g/cm (95% CI, 1.10, 1.29)] (difference in means, 0.01; 95% CI, 0.004, 0.01; P = 0.26).

CONCLUSIONS

These results confirm that Predocol is effective treatment for acute ulcerative colitis and short courses of the steroid have no adverse effects on bone formation and bone mineral density. The encouraging results from this study suggest that Predocol may be a significant advance in preventing corticosteroid induced bone loss in ulcerative colitis.

Five year study of etidronate and/or calcium as prevention and treatment for osteoporosis and fractures in patients with asthma receiving long term oral and/or inhaled glucocorticoids

BACKGROUND

Glucocorticoids are associated with a reduction in bone density and an increased risk of fracture. Concurrent treatment with bisphosphonates reduces bone loss and may prevent fractures. A randomised study was performed to determine whether treatment with cyclical etidronate and/or calcium for 5 years prevents fractures or reverses/reduces bone loss in patients receiving glucocorticoid treatment for asthma.

METHODS

A multicentre, randomised, parallel group comparison of etidronate alone, calcium alone, etidronate + calcium, and no treatment, with stratification according to level of glucocorticoid exposure was carried out in 39 chest clinics in the UK. Three hundred and forty nine postmenopausal female and male outpatients with asthma aged 50-70 years were randomised. The main outcome measures were fractures and changes in bone mineral density (BMD).

RESULTS

Overall, 8% of the patients experienced symptomatic fractures and 17.5% developed either a symptomatic fracture and/or a semiquantitative vertebral fracture by the end of 5 years There were no significant differences between the four treatment groups. Comparing etidronate with no etidronate, the rates of new fractures were not significantly different for symptomatic fractures (OR 1.07 (95% CI 0.46 to 2.47)) or for any fractures (OR 0.82 (95% CI 0.45 to 1.47)). For the comparison of calcium with no calcium the corresponding ORs were 1.43 (95% CI 0.62 to 3.33) and 0.91 (95% CI 0.50 to 1.63). In post hoc analysis the effect of etidronate was greater in women than in men (interaction p value 0.02) with the fracture incidence roughly halved (OR 0.39, 95% CI 0.14 to 0.99). Etidronate increased BMD at the lumbar spine by 4.1% (p = 0.001) while calcium had no significant effect. At the proximal femur the effects of treatment were not significant (relative increases etidronate 1.6%; calcium 1.1%). The rate of new fractures in patients with fractures at entry (23.7%) was higher than in those without fractures at entry (14.3%): OR 1.87 (95% CI 1.06 to 3.07). No association was found between change in BMD and new fractures.

CONCLUSIONS

In patients receiving glucocorticoids for asthma etidronate significantly increased BMD over 5 years at the lumbar spine but not at the hip and had little if any protective effect against fractures, except possibly in postmenopausal women. The effects of calcium were not significant. Combination treatment had no advantage but increased unwanted effects.

The treatment of glucocorticoid-induced osteoporosis

Glucocorticoid use results in an increase risk for fractures. Over the past 10 years, we have a greater understanding of the epidemiology, pathophysiology, prevention and treatment of glucocorticoid induced osteoporosis. This article reviews these recent findings and selective practice guidelines.

La maladie de Horton compliquée : modalités thérapeutiques

FORMS THAT RAISE THERAPEUTIC PROBLEMS: The complicated forms of Horton's syndrome regroup various situations: ocular involvement at the start, large vein involvement, corticosteroid resistance (rare), corticosteroid dependence preventing the reduction in the daily dose of prednisone to less than 15 mg, high rate of morbidity with prolonged corticosteroid therapy. GENERAL PRINCIPLES: The ocular forms and those with large vein involvement, require a minimal attack treatment with 1mg/kg/d of prednisone. Cortisone assaults are often prescribed despite the fact that their efficacy remains to be demonstrated. Curative treatment with heparin (calcic or of low molecular weight) should be prescribed for 5 to 7 days with later relay to a platelet anti-aggregant, without any randomised study having validated this proposition. THE CASE OF CORTICOSTEROID-DEPENDENCE: The iatrogenic risk of corticosteroids is high and alternative treatments should be proposed: azathioprine, methotrexate, dapsone or hydroxychloroquine. Osteoporosis is the most frequent complication of corticosteroid therapy and must be avoided by the administration of a biphosphonate.

Prevention of fractures in older people who fall

Despite assessment and appropriate interventions, some older people will continue to be at risk of falling. Fractures of the hip and wrist are especially common among this group. The risk of fracture means that a comprehensive falls prevention programme must include an assessment of the individual fracture risk and the instigation of appropriate treatment of bone fragility. Osteoporosis is the main cause of bone fragility in this client group and it is commonly associated with postmenopausal women, although other forms exist. Osteoporosis is also a problem for men as they get older and for individuals taking steroid medications. Community nurses need to be aware of how osteoporosis manifests itself as well as how this condition can be prevented and treated.

Glucocorticoid-induced osteoporosis

Therapeutic use of glucocorticoids can lead to many well-known adverse events. Of all potential serious side effects, glucocorticoid-induced osteoporosis (GIOP) is one of the most devastating complications of protracted glucocorticoid therapy in rheumatoid arthritis. GIOP is the most common form of drug-induced osteoporosis. Although much has been written about the association of glucocorticoids with bone disease among patients with chronic inflammatory conditions, many issues remain unsettled. This article focuses on areas of continued controversies, including the epidemiology and pathogenesis of GIOP, specification of a "safe" dose, methods for diagnosis of GIOP, and an evidence-based approach for GIOP prevention.

Treatment of inflammatory bowel disease in childhood: best available evidence

The physician treating children with inflammatory bowel disease is confronted with a number of specific problems, one of them being the lack of randomized, controlled drug trials in children. In this review, the role of nutritional therapy is discussed with a focus on primary treatment, especially for children with Crohn's disease. Then, the available medical therapies are highlighted, reviewing the evidence of effectiveness and side effects in children, as compared with what is known in adults. Nutritional therapy has proven to be effective in inducing and maintaining remission in Crohn's disease while promoting linear growth. Conventional treatment consists of aminosalicylates and corticosteroids, whereas the early introduction of immunosuppressives (such as azathioprine or 6-mercaptopurine) is advocated as maintenance treatment. If these drugs are not tolerated or are ineffective, methotrexate may serve as an alternative in Crohn's disease. Cyclosporine is an effective rescue therapy in severe ulcerative colitis, but only will postpone surgery. A novel strategy to treat Crohn's disease is offered by infliximab, a monoclonal antibody to the proinflammatory cytokine tumor necrosis factor (TNF)-alpha. Based on the best-available evidence, suggested usage is provided for separate drugs with respect to dosage and monitoring of side effects in children.

Corticosteroid-induced osteoporosis in patients with uveitis

AIMS

To estimate the prevalence of low bone density and osteoporosis in a population of patients with uveitis taking systemic steroid treatment; to clarify the risks of steroid-induced fracture and to suggest a protocol for the prevention and management of bone loss in patients with ophthalmic inflammatory disease.

METHODS

Bone densitometry was performed on 129 adult patients with prednisolone-treated uveitis from four centres. Information on uveitis diagnosis, associated risk factors, steroid dosage and treatment duration, prophylaxis and management, was collected. Juveniles, patients with scleritis and those who had used deflazacort, were excluded.

RESULTS

Steroid treatment time varied from 13 weeks to 31 years, and the total dosage from 1.29 g to 166.5 g. Twenty-six percent of patients also used one or more immunosuppressives. Forty-eight percent had additional risk factors for bone loss. Bone density was abnormally low in 44.2%, and 15.5% had osteoporosis. Osteoporosis was substantially more common in males (20.6%, all under 60 yrs) than in females (9.8%). Seven symptomatic fractures occurred in patients on treatment. Bone loss correlated with total steroid dose, mean dose, duration of treatment and the presence of pre-existing risk factors.

CONCLUSIONS

The prevalence of steroid-induced osteoporosis and fracture is low for patients with uveitis but young males are at risk. Patients at high risk should be identified, and prophylaxis and treatment should be used as required. The guideline of the National Osteoporosis Society is recommended as a management protocol.

Corticosteroid-Induced osteoporosis: detection and management

Corticosteroid-induced osteoporosis is a major cause of morbidity and is the leading secondary cause of osteoporosis today. Unfortunately, despite this knowledge, patients receiving corticosteroid therapy are often not offered any preventative treatment. Recent research has focused attention on the critical role the osteoblast has played in the pathophysiology of corticosteroid-induced osteoporosis. In addition to an initial increase in bone resorption, there is evidence that corticosteroids induce osteoblast and osteocyte apoptosis and as a result are important contributors to bone loss. Interesting work has suggested that the bisphosphonates and calcitonin may help to prevent osteoblast apoptosis from occurring. Large scale randomised controlled trials have also been completed with a variety of therapeutic agents. Of the many different therapies, it is now clear that the bisphosphonates have the greatest evidence to support their use. Increases in bone mineral density when compared with a control group, not only at the spine but also at the hip, have been demonstrated. These studies have shown clinically significant reductions in vertebral fracture rates seen for the most part in postmenopausal women. Other therapies may well be effective, as evidenced by maintenance of bone mass in the spine; however, maintenance of bone mass in the hip and reductions in fracture rate have yet to be demonstrated for many of these therapies. Given our current knowledge and the evidence that is outlined in this review, it is hoped that patients who require therapy with corticosteroids for more than 3 months will be offered appropriate preventative treatment.

Corticosteroid-Induced Osteoporosis

Corticosteroid-induced osteoporosis is the leading cause of secondary osteoporosis and a significant cause of morbidity in both men and women. Long-term use of even low-dose corticosteroids has been associated with increased risk of bone loss. Recent large randomized controlled trials have generated new knowledge on treatment strategies for patients with corticosteroid-induced osteoporosis. However, the majority of individuals receiving corticosteroids are not receiving prophylaxis for osteoporosis. Calcium and vitamin D should be recommended to patients initiating therapy with corticosteroids (and should be adequate for those receiving corticosteroids for less than 3 months). For those receiving corticosteroids for greater than 3 months, bisphosphonates are the therapy of choice, with both alendronate (alendronic acid) and risedronate (risedronic acid) approved by the US FDA for use in this indication. Calcitonin can be considered a second-line agent and should be reserved for patients who are intolerant of bisphosphonates or who are experiencing pain from a vertebral fracture. Hormone replacement therapy or testosterone therapy may be offered to those individuals on long-term corticosteroid treatment who are hypogonadal. Teriparatide (recombinant human parathyroid hormone 1-34) shows promise as a future anabolic agent for the prevention and treatment of patients with corticosteroid-induced osteoporosis.

Alendronate for the prevention of bone loss in patients on inhaled steroid therapy

One hundred women on inhaled steroid therapy (dose range from 800 to <1600 microg per day) were randomized to receive 10 mg of oral alendronate or placebo (with 500 mg of calcium in the form of daily calcium carbonate). Bone mineral density (BMD) was measured at baseline, 6 months, and 12 months. The percentage changes in BMD were -0.80% in the placebo group and 2.99% in the alendronate group at the spine (p < 0.001 by analysis of covariance [ANCOVA]), and were -0.51% in the placebo group and 0.97% in the alendronate group at the femoral neck (p < 0.05 by ANCOVA). Five patients in the alendronate-treated group, and a similar number of patients in the placebo group, complained of mild gastric discomfort. We conclude that women on inhaled steroid therapy were at risk of accelerated bone loss, which could be prevented by a daily dose of 10 mg of alendronate.

Primary prevention of glucocorticoid-induced osteoporosis with intravenous pamidronate and calcium: a prospective controlled 1-year study comparing a single infusion, an infusion given once every 3 months, and calcium alone

The aim of this study was to compare the action of two regimens of intravenous (iv) pamidronate in the primary prevention of glucocorticoid-induced osteoporosis (GC-OP). The primary purpose of the study was to determine whether any differences in bone mineral density (BMD) appeared after 1 year. A secondary endpoint aimed at assessing the remodeling parameters in order to better understand the mechanisms of action of the various regimens. Thirty-two patients, who required first-time, long-term glucocorticoid therapy at a daily dose of at least 10 mg of prednisolone, were studied. Simultaneously with the initiation of their glucocorticoid treatment, patients also were randomly allocated to receive a single iv infusion of 90 mg of pamidronate at the start (group A); a first infusion of 90 mg of pamidronate followed, subsequently, by an iv infusion of 30 mg pamidronate every 3 months (group B); and a daily 800-mg elemental calcium supplement given as calcium carbonate (group C), which also was taken by patients in groups A and B. Patients were matched for starting glucocorticoid doses, sex, menopausal status, and hormonal replacement therapy. Lumbar spine and hip (total and subregions) BMDs were measured at the outset and repeated at 6-month intervals by dual-energy X-ray absorptiometry (DXA; Hologic QDR-2000). Bone turnover was assessed by measurement of total and bone-specific serum alkaline phosphatase activity (B-ALP), serum osteocalcin (OC), and serum C-telopeptide cross-links of type I collagen (CTX). After 1 year, the mean BMD changes for groups A, B, and C were, respectively, 1.7, 2.3, and -4.6% at the lumbar spine; 1.2, 1.2, and -3.1% at the femoral neck; 1.0, 2.6, and -2.2% for the total hip region. No difference was observed between pamidronate regimens but a highly significant difference was observed between both pamidronate regimens and the control group at the lumbar spine (p < 0.001), at the femoral neck (p < 0.01), and for the total hip (p < 0.05). A significant decrease of serum C-telopeptide was observed, after 3 months, in groups A and B (p = 0.029), but a sustained decrease of bone resorption over time was observed only in group B. As far as BMD evolution over 1 year was concerned, iv pamidronate, given either as a single infusion or once every 3 months, effectively achieved primary prevention of GC-OP.

Management of osteoporosis in primary biliary cirrhosis

Osteoporosis is not a significant problem in the majority of patients with primary biliary cirrhosis (PBC). However, substantial bone-related morbidity may occur in patients with advanced disease, in particular after liver transplantation. The cause of osteoporosis in PBC is multifactorial, and pathophysiological mechanisms specifically related to PBC have not been defined. In general, the principles of management followed in post-menopausal osteoporosis also apply in chronic liver disease. Dual energy X-ray absorptiometry is currently the method of choice for monitoring bone mineral density. Avoidance of conditions with potential negative effects on bone mass, and maintaining adequate serum vitamin D levels and calcium intake form the cornerstone in preventing osteoporosis. Bisphosphonates are the most logical choice when specific medical treatment of PBC-associated osteoporosis is indicated, as well as for preventing bone loss during glucocorticoid treatment and after liver transplantation. Recent studies suggest that active vitamin D analogues are effective alternatives in the post-transplant setting.

Acute effects of etidronate on glucocorticoid-induced bone degradation

OBJECTIVES

To study the acute short-term effects on the biochemical parameters of calcium and bone homeostasis in post-menopausal women treated with a high dose of prednisone alone or with additional etidronate, before and during 5 days of treatment.

METHODS

Serum calcium, phosphorus, creatinine, alkaline phosphatase activity, osteocalcin, carboxy-terminal propeptide of type I procollagen (PICP), cross-linked carboxy-terminal telopeptide of type I collagen (ICTP), parathyroid hormone (PTH), 25-hydroxyvitamin D and urinary excretion of calcium over 24 h were measured before and during 5 days of treatment in 14 post-menopausal women treated with a high dose of prednisone (60 mg/day) alone (group A) or combined with cyclical etidronate (group B).

RESULTS

Significant differences from baseline were found in osteocalcin and urinary excretion of calcium in both groups and for ICTP in group B. Significant differences between groups were calculated at day 5 of the study for osteocalcin, ICTP and 24 h urine calcium excretion (P < 0.01). Urinary excretion of calcium over 24 h increased in group A (+14.7%; P < 0.05) and decreased in group B (-22.1%; P < 0.01). Osteocalcin levels decreased in group A (- 38.1%) and increased in group B (+27.4%; both P < 0.01). ICTP decreased only in group B (-19.4%; P < 0.01).

CONCLUSIONS

The results are consistent with the fact that etidronate is acutely able to prevent bone resorption due to corticosteroids. The increase in osteocalcin in the etidronate-treated group is a new feature. A direct or indirect (PTH, 1,25 vitamin D?) stimulatory effect of etidronate on the osteoblast cannot be excluded.

Steroid-induced osteoporosis in systemic lupus erythematosus

The patient with SLE is at considerable risk of osteoporosis, because of the inflammatory disease itself, its consequences, and its treatments. Because of their extensive use, glucocorticoids are thought to be the most frequent cause of drug-related osteoporosis and may be responsible for much of the bone loss in lupus. This article focuses on the mechanisms of steroid-induced osteoporosis in SLE and outlines strategies for prevention and treatment.

Osteoporosis due to cancer treatment: pathogenesis and management

Many therapeutic regimens in cancer treatment carry the risk of causing or favoring the development of osteoporosis. Therapies in which hypogonadism may occur are most relevant in this respect. Prompt hormone replacement therapy is indicated in these patients. In patients in whom this is undesirable because of a hormone-dependent tumor, the risk of osteoporosis should be assessed by means of osteodensitometry, and prophylactic or therapeutic measures should be instituted if necessary. Early intervention improves outcome because osteoporosis therapy is most effective in preventing deterioration of bone mass. There remains much uncertainty in assessing the risk of combination chemotherapy with regard to the development of osteoporosis. Negative effects on the skeleton have, however, been demonstrated for individual drugs, such as methotrexate and ifosfamide. Negative effects of the tumor itself on bone metabolism may aggravate the degree of osteoporosis. Detailed data and long-term experience to assess the risk are urgently needed in this area and constitute an important research topic for the coming years and decades. This review discusses the most prevalent mechanisms of osteoporosis caused by cancer treatment and outlines therapeutic strategies for the prevention and treatment of therapy-induced bone loss.

A multidisciplinary renal clinic for corticosteroid-induced bone disease

A multidisciplinary clinic to manage complicated bone disease was established due to the high prevalence of osteoporosis in corticosteroid-treated patients with a history of organ transplantation or chronic glomerulonephritis. Assessments were performed by a renal clinical pharmacist, nephrology nurse, and rheumatologist. Of 70 patients (27 men, 43 women) evaluated from December 1997-June 1999, 37% had osteoporosis (30% spine, 23% hip, 16% both sites) and 34% had a history of fracture. Analysis revealed low 1,25-hydroxyvitamin D3 levels (15 patients), hormone deficiency (16), elevated parathyroid hormone (27), and history of taking at least one other risk drug in addition to corticosteroids (58). Thirty-nine percent of patients had a documented height loss (mean 1.0 in.). Other risk factors included 32 episodes of graft rejection requiring additional corticosteroids, history of smoking (24 patients), poor physical activity (40), and low dietary calcium intake (47). Drug interventions included calcium and/or vitamin D (44 patients), calcitonin (7), alendronate (20), and hormone replacement therapy (11). Preliminary results showed an increase in bone mineral density (a surrogate marker for fracture risk) of 3-5%. An organized clinic to assess osteoporosis risks can unmask a large population of patients with documented bone loss. Appropriate interventions such as drug therapy and lifestyle changes may increase bone mineral density. A long-term benefit of therapy, although not measured in this study, may be a decreased predisposition to fractures and their sequelae.

Management of corticosteroid-induced osteoporosis

OBJECTIVES

To educate scientists and health care providers about the effects of corticosteroids on bone, and advise clinicians of the appropriate treatments for patients receiving corticosteroids.

METHODS

This review summarizes the pathophysiology of corticosteroid-induced osteoporosis, describes the assessment methods used to evaluate this condition, examines the results of clinical trials of drugs, and explores a practical approach to the management of corticosteroid-induced osteoporosis based on data collected from published articles.

RESULTS

Despite our lack of understanding about the biological mechanisms leading to corticosteroid-induced bone loss, effective therapy has been developed. Bisphosphonate therapy is beneficial in both the prevention and treatment of corticosteroid-induced osteoporosis. The data for the bisphosphonates are more compelling than for any other agent. For patients who have been treated but continue to lose bone, hormone replacement therapy, calcitonin, fluoride, or anabolic hormones should be considered. Calcium should be used only as an adjunctive therapy in the treatment or prevention of corticosteroid-induced bone loss and should be administered in combination with other agents.

CONCLUSIONS

Bisphosphonates have shown significant treatment benefit and are the agents of choice for both the treatment and prevention of corticosteroid-induced osteoporosis.

Glucocorticoid-induced osteoporosis

This article attempts to evaluate the results of several recently published clinical trials of drugs used in the treatment and prevention of glucocorticoid-induced osteoporosis. Despite our lack of understanding regarding the biological mechanisms that lead to glucocorticoid-induced bone loss, effective therapy has been developed. Bisphosphonates have demonstrated significant treatment benefits and should be considered the therapy of choice for both the treatment and prevention of glucocorticoid-induced osteoporosis.

Etridronate therapy in the treatment and prevention of osteoporosis

Etidronate disodium is an oral bisphosphonate compound known to reduce bone resorption through the inhibition of osteoclastic activity. This article is a review of its efficacy and safety in the treatment and prevention of postmenopausal and corticosteroid-induced osteoporosis. In general, studies of cyclical etidronate therapy (400 mg daily for 2 wk every 3 mo) have found a significant improvement in bone density. These studies have not been powered to study fracture incidence, but a reduced fracture rate has been found in some of the studies reviewed. Studies examining cyclical etidronate in the prevention of osteoporosis indicate it prevents early menopausal bone loss and is free of significant side effects. In both prevention of corticosteroid-induced osteoporosis and treatment of patients who have been on long-term corticosteroid therapy, cyclical etidronate appears to increase bone density and prevent further loss of bone. In summary, a review of available literature pertaining to the use of etidronate in prevention and treatment of primary and secondary osteoporosis has been presented. This review suggests etidronate, used as a cyclical therapy, is a safe and effective therapy. The weight of evidence suggests it is capable of reducing fracture risk in patients with osteoporosis. Increases in bone density at the spine and hip are not as pronounced as with some other bisphosphonates, particularly alendronate, but no direct clinical comparison trials of significant size or duration have been undertaken.

Bisphosphonates for steroid induced osteoporosis

OBJECTIVES

To assess the effects of bisphosphonates for the prevention and treatment of corticosteroid-induced osteoporosis.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group trials register, Medline up to 1997 and Embase1988-1997), and selected hand searching of reference lists was conducted. Hand searching of scientific abstracts from relevant meetings for the last five years was also done. An electronic search in Current Contents was done for the last six months. The Cochrane Controlled Trials Register (CCTR) will be searched for future updates. All languages were included in the search. For practical reasons only those in English were included, but all languages will be retrieved and translated for future updates.

SELECTION CRITERIA

All controlled clinical trials (CCTs) dealing with prevention or treatment of corticosteroid-induced osteoporosis with bisphosphonates of any type and reporting the outcomes of interest were assessed. Trials had to involve adults only, and subjects had to be taking a mean steroid dose of 7.5 mg/day or more.

DATA COLLECTION AND ANALYSIS

All data extraction was performed by two independent reviewers. Outcomes of interest included change in bone mineral density (BMD) at the lumbar spine and femoral neck at six and 12 months. If present, data on number of new fractures and withdrawals due to adverse effects were also extracted. All data extraction was performed by two independent reviewers. Both continuous and dichotomous data were analyzed using fixed effects models. When significant heterogeneity was present, a random effects model was used.

MAIN RESULTS

A total of 13 trials, including 842 patients are included in this meta-analysis. Results are reported as a weighted mean difference of the percent change in BMD between the treatment and placebo groups, with trials being weighted by the inverse of their variance. The 95% confidence intervals (95% CI) are presented. At the lumbar spine, the weighted mean difference of BMD between the treatment and placebo groups was 4.3% (95% CI 2.7, 5.9). At the femoral neck, the weighted mean difference was 2.1% (95%CI 0. 01, 3.8). Although there was a 24% reduction in odds of spinal fractures [OR 0.76 (95%CI 0.37, 1.53)], this result was not statistically significant.

REVIEWER'S CONCLUSIONS

Bisphosphonates are effective at preventing and treating corticosteroid-induced bone loss at the lumbar spine and femoral neck. Efficacy regarding fracture prevention cannot be concluded from this analysis, although bone density changes are correlated with fracture risk.