Recognizing and treating glucocorticoid-induced osteoporosis in patients with pulmonary diseases

Potential Predictive of Thoracic CT Value and Bone Mineral Density T-Value in COPD Complicated with Osteoporosis

Background

COPD, combined with Osteoporosis, has a high incidence and potential for great harm. Choosing an optimal diagnostic method to achieve bone mineral density (BMD) screening is crucial for COPD patients. Studies on COPD patients with BMD reduction are lacking.

Purpose

To identify the risk factors of BMD reduction and osteoporosis in COPD patients.

Patients and Methods

We included a total of 81 patients with AECOPD, who were admitted to the hospital from July 1, 2019, to January 31, 2020. Patients were grouped into BMD normal group, BMD reduced group and OP group. The areas under ROC curve were used to explore the value of CT values in the diagnosis of bone abnormality, and clinical indicators were collected.

Results

The CT value of the vertebral cancellous bone is highly correlated with the T value of BMD (R > 5.5, P < 0.0001). Using multivariate Logistic regression analysis, we showed that COPD duration, BMI, 25-hydroxyvitamin D3, and long-term inhaled glucocorticoid were independent factors affecting different BMD levels in COPD patients. No significant difference in bone formation indexes between groups. β-crossL was negatively correlated with serum IL-6 (r=-0.254, P=0.022), and ALP was positively correlated with serum TNF-α (r=0.284, P=0.023).

Conclusion

Thoracolumbar vertebral cancellous bone CT has potential value in the diagnosis of bone abnormality. COPD duration, BMI, 25-hydroxyvitamin D3, and long-term inhaled glucocorticoid may contribute to the BMD reduction in COPD patients, and serum IL-6 and TNF-α regulate bone metabolism in COPD patients.

Effects of Supplementation in Vitamin D3 Deficient or Insufficient Children with Allergic Diseases

Background and Objectives: Although vitamin D insufficiency or deficiency is prevalent in children with allergic diseases, recommendations for supplementation dosing regimens are imprecise and variable in the literature, because clinical trials aiming to determine optimal doses were scarce in the past. This study aimed to investigate supplementation of vitamin D3 that may achieve therapeutically effective but not toxic serum levels in a subpopulation of children with allergic diseases and concomitant hypovitaminosis D. Materials and Methods: The retrospective, observational study with a cross-sectional design included 94 children suffering from allergic diseases and having vitamin D deficiency/insufficiency who were prescribed high-dose vitamin D3 supplementation by a pediatrician for at least 6 weeks and not more than 9 weeks. Serum levels of the major metabolite of vitamin D (25-(OH)D) were determined in all children twice: before and two weeks after the end of vitamin D3 supplementation. Results: An increase in serum level of the 25-(OH)D after supplementation was significant. However, if the subjects had higher serum levels of the 25-(OH)D before the supplementation, and if the supplementation lasted 8 instead of 6 weeks, the absolute increase in serum level of the 25-(OH)D was lower. Patients taking corticosteroids as inhalation or intranasally had a more intense effect of vitamin D3 supplementation, i.e., the absolute increase in levels of 25-(OH)D was higher than in patients not using such medication. Conclusions: Vitamin D deficiency and insufficiency in children with allergic diseases can be treated with maximal recommended doses of vitamin D3 for a short period of time, especially if they were prescribed with inhalation or intranasal corticosteroids.

Inhaled corticosteroids and the risks of low-energy fractures in patients with chronic airway diseases: A propensity score matched study

BACKGROUND AND AIMS

Inhaled corticosteroids (ICSs) are crucial anti-inflammatory medications for chronic airway diseases. Studies investigating the relationship between ICSs and fractures in Asian populations are scant. We investigated whether ICSs increased the risk of low-energy fractures in patients with chronic airway diseases.

METHODS

We used the Longitudinal Health Insurance Database to select patients aged 20 years and older with chronic airway diseases (asthma and COPD) between 2000 and 2011 as the base cohort. We identified ICS users and ICS non-users matched by propensity score method at 1:1 ratio. Cox proportional hazard regression models were used to calculate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) for factors associated with the risk of fracture.

RESULTS

A total of 1,182 ICS users and 1,182 controls were enrolled. After adjustment for age, gender, annual exacerbation number of acute respiratory events, comorbidity and medications, the risk of fracture was 1.10 for ICS users (aHR = 1.20; 95% CI = 1.10-1.31) compared with ICS non-users. The ICS users exhibited significantly 1.63-fold risk of hip fracture and 1.24-fold risk of ulna and radius fracture than did the ICS non-users. Patients with medium and high doses of ICS use were associated with significantly increased risks of fracture (aHR = 1.48, 95% CI = 1.25-1.76 for medium dose and aHR = 1.55, 95% CI = 1.39-1.72 for high dose) compared with those in ICS non-users.

CONCLUSIONS

Patients with medium and high doses of ICS use are associated with an increased risk of fracture.

Osteoporosis self-reported in the elderly: a population-based survey in the city of Campinas, São Paulo, Brazil

INTRODUCTION

Osteoporosis is a multifactorial disease that predisposes individuals to suffer falls and fractures, causing functional impairment and a consequent reduction in quality of life.

OBJECTIVE

To assess the prevalence and factors associated with self-reported osteoporosis in the elderly population living in Campinas, São Paulo, Brazil (ISACAMP 2008).

METHODS

Cross-sectional study with a random sample taken by conglomerates in 2 stages totaling 1,419 elderly people living in the urban area. The self-reported prevalence of osteoporosis was estimated according to socioeconomic and demographic variables, morbidity, health behaviors and problems. Crude prevalence ratios were estimated and adjusted by means of simple and multiple regressions using the Poisson svy commands in Stata 11.0 software.

RESULTS

We found a prevalence of osteoporosis of 14.8%, and significantly higher in females, in individuals who reported white skin, those who reported less than 7 hours of sleep/day, in patients with rheumatism/arthritis/arthrosis, asthma/bronchitis/emphysema, tendinitis, dizziness, insomnia, common mental disorders, BMI < 27, health self-related as bad and very bad, and reporting falls occurring in the last 12 months.

CONCLUSION

The present study, by identifying the factors associated with osteoporosis, identified segments of older people with a higher prevalence of the disease; to this information may contribute to the planning of public health policies and programs aimed at controlling the disease and its consequences.

A National Analysis of Complications Following Total Hip Replacement in Patients With Chronic Obstructive Pulmonary Disease

Patients with chronic obstructive pulmonary disease (COPD) have a high risk of osteoporosis and fractures. The incidence rate of hip fracture has steadily increased over time and is a major common event in patients with osteoporosis and COPD. Total hip replacement (THR) is commonly performed in patients with hip fracture. Our aim was to compare the complications of THR between patients with and without COPD.Longitudinally linked data from the National Health Insurance Research Database, which consists of registration, claims, and reimbursement records, for a cohort of 1,000,000 randomly selected enrollees traced retrospectively from 1996 to 2000 in Taiwan. Patients who had undergone THR surgery between January 1, 2004, and December 31, 2008, were identified and divided into COPD and non-COPD cohorts. Outcomes and complications, including 90-day mortality, 1-year mortality, 1-year wound infection, 30-day readmission for hospitalization, 30-day pneumonia, 30-day acute respiratory failure, 30-day cerebrovascular accident, and length of stay during hospitalization, were measured after THR.The COPD group had a significantly higher ratio of complications, including 30-day readmission (14.0% vs 8.4%), 30-day pneumonia (10.4% vs 4.4%), 30-day acute respiratory failure (1.5% vs 0.5%), 1-year mortality (6.9% vs 2.7%), and length of stay in the hospital (10.6% vs 0.8%) than the non-COPD group.In addition to airway diseases, patients in the COPD group had higher mortality than those in non-COPD group after THR. Surgeons should give more attention to airway evaluation and selection of patients with COPD for THR.

[National consensus regarding the prescription of inhaled corticosteroids in cystic fibrosis]

The conditions for the prescription of inhaled steroids (ISs) in cystic fibrosis (CF) are not well established.

AIM

To propose a formalized consensus agreement regarding the prescription of ISs in this disease.

MATERIAL AND METHODS

Application of the Delphi method in five thematic fields: indications, non-indications, dosage, precautions for use, and treatment follow-up.

RESULTS

Thirty of forty-nine (61 %) reference CF centers in France participated in the process, which comprised three rounds. Experts strongly agreed that ISs are indicated in the presence of pulmonary manifestations with wheezing, personal history of atopy, and/or bronchial hyper-responsiveness. In contrast, ISs are not indicated as first-line therapy for allergic bronchopulmonary aspergillosis. Strong agreement was reached regarding the daily dose of ISs, which should be similar to what is given in asthma and adapted to control symptoms so as to prescribe the smallest possible dose. Increasing the frequency of bacterial and fungal sputum analyses and eye (cataract) assessments was not deemed necessary. However, in case of prolonged (>6months) use of high-dose ISs, monitoring bone mineral density and the hypothalamic-pituitary-adrenal axis, in particular if itraconazole is concomitantly prescribed, was recommended.

CONCLUSION

This consensus statement defines a perimeter for the prescription of ISs in CF, with the aim of limiting their prescription (until new data are available).

Bone density in heart or lung transplant recipients--a longitudinal study

BACKGROUND

Osteoporosis is prevalent among heart or lung transplant (HLT) candidates. Bone loss is common posttransplant, with an associated increase in fracture risk. There is a lack of consensus regarding optimal management of bone health in HLT recipients. We report bone health data in a cohort of HLT recipients before and after transplantation and make recommendations for management.

METHODS

Patients over the age of 20 who had a heart or lung transplant between 2000 and 2011 were identified from the New Zealand HLT Service database, and demographic data, immunosuppressive regimens, bisphosphonate use, and serial bone mineral density (BMD) data were extracted.

RESULTS

Pretransplant BMD was available in 52 heart and 72 lung transplant recipients; 30 and 42, respectively, also had posttransplant BMD data. Pretransplant osteopenia or osteoporosis prevalence were 23% and 8% for heart candidates and 36% and 31% for lung candidates. Posttransplant, BMD decreased significantly at the femoral neck but not at the lumbar spine in the first year, with subsequent stabilization particularly in the presence of bisphosphonate use. Pretransplant BMD was the major predictor for developing osteopenia or osteoporosis after transplantation.

CONCLUSION

A significant proportion of HLT recipients have osteopenia or osteoporosis pretransplant, and this persists posttransplant. Pretransplant BMD is an important predictor of subsequent osteopenia or osteoporosis development, allowing risk stratification and targeted intervention.

Time trends for alendronate prescription practices in women with chronic obstructive pulmonary disease and women exposed to systemic glucocorticoids

Chronic obstructive pulmonary disease (COPD) and systemic glucocorticoid exposure are well-known risk factors of osteoporosis. We evaluated alendronate prescription practices related to COPD and exposure to systemic corticosteroids from 1996 to 2008 and showed an increasing targeting of alendronate treatment in patients with COPD and patients with systemic corticosteroid exposure.

INTRODUCTION

COPD and systemic glucocorticoid exposure are well-known risk factors of osteoporosis and fragility fracture, but osteoporosis is often underdiagnosed and undertreated in these patients. This study aims to evaluate alendronate prescription practices related to COPD and/or to exposure to systemic glucocorticoids among Danish women.

METHODS

A total of 388,314 female subjects >50 years old, 64,719 of whom initiated treatment with alendronate, and 323,595 age- and gender-matched controls were retrospectively identified between 1996 and 2008 from national health registers. Multivariate logistic regression was used for examining prescription practices, specifically if these risk factors (COPD or glucocorticoid exposure) increased or decreased the likelihood of beginning alendronate therapy.

RESULTS

A diagnosis of COPD was associated with an increased likelihood of using alendronate (odds ratio (OR) 1.4, 95 % confidence interval (CI) 1.4-1.5, p < 0.001). Further, a diagnosis of COPD was associated with an increasing tendency of initiating alendronate treatment in the study period (OR 1.3 (95 % CI 1.1-1.5, years 1996-1999) to 1.5 (95 % CI 1.4-1.6, years 2006-2008), p < 0.01). Exposure to systemic glucocorticoids was associated with a significantly increasing (OR 3.6, 95 % CI 3.3-3.9 to OR 5.5, 95 % CI 5.3-5.8) probability of receiving alendronate treatment in the same observation period.

CONCLUSION

This nationwide register-based study on alendronate prescription practices in Denmark shows an increasing targeting of alendronate treatment in patients with COPD and an even stronger trend for patients with systemic glucocorticoid exposure, perhaps indicating increased awareness of well-known and associated conditions.

Bone disease in organ transplant patients: pathogenesis and management

Bone disease is common in recipients of kidney, heart, lung, liver, and bone marrow transplants, and causes debilitating complications, such as osteoporosis, osteonecrosis, bone pain, and fractures. The frequency of fractures ranges from 6% to 45% for kidney transplant recipients to 22% to 42% for heart, lung, and liver transplant recipients. Bone disease in transplant patients is the sum of complex mechanisms that involve both preexisting bone disease before transplant and post-transplant bone loss due to the effects of immunosuppressive medications. Evaluation of bone disease should preferably start before the transplant or in the early post-transplant period and include assessment of bone mineral density and other metabolic factors that influence bone health. This requires close coordination between the primary care physician and transplant team. Patients should be stratified based on their fracture risk. Prevention and treatment include risk factor reduction, antiresorptive medications, such as bisphosphonates and calcitonin, calcitriol, and/or gonadal hormone replacement. A steroid-avoidance protocol may be considered.

Does radiographic emphysema correlate with low bone mineral density?

PURPOSE OF REVIEW

Several large epidemiologic studies have shown an association between chronic obstructive pulmonary disease (COPD) and osteoporosis. Recent studies have further implied an emphysema-specific association with low bone mineral density independent of obstruction severity.

RECENT FINDINGS

This review will outline the studies demonstrating an independent association between radiographic emphysema and decreased bone mineral density and will discuss potential disease mechanisms, including systemic inflammation and immune-mediated factors, linking these disease processes.

SUMMARY

Radiographic emphysema should be considered an independent risk factor in studies examining the mechanisms underlying COPD-related bone loss. Future research focused on the relationship between emphysema and low bone mineral density could provide mechanistic insight and result in the development of targeted therapies designed to halt progression of both disease processes.

Skeletal microstructural abnormalities in postmenopausal women with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is associated with osteoporosis and fragility fractures. The objectives of this study were to assess static and dynamic indices of cancellous and cortical bone structure in postmenopausal women with COPD. Twenty women with COPD who had not received chronic oral glucocorticoids underwent bone biopsies after double tetracycline labeling. Biopsies were analyzed by histomorphometry and µCT and compared with age-matched controls. Distribution of the patients according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was: Type I (15%), Type II (40%), Type III (30%), and Type IV (15%). Mean (±SD) cancellous bone volume (15.20 ± 5.91 versus 21.34 ± 5.53%, p = .01), trabecular number (1.31 ± 0.26 versus 1.77 ± 0.51/mm, p = .003), and trabecular thickness (141 ± 23 versus 174 ± 36 µm, p = .006) were lower in patients than in controls. Connectivity density was lower in COPD (5.56 ± 2.78 versus 7.94 ± 3.08/mm, p = .04), and correlated negatively with smoking (r = -0.67; p = .0005). Trabecular separation (785 ± 183 versus 614 ± 36 µm, p = .01) and cortical porosity (4.11 ± 1.02 versus 2.32 ± 0.94 voids/mm(2); p < .0001) were higher in COPD while cortical width (458 ± 214 versus 762 ± 240 µm; p < .0001) was lower. Dynamic parameters showed significantly lower mineral apposition rate in COPD (0.56 ± 0.16 versus 0.66 ± 0.12 µm/day; p = .01). Patients with more severe disease, GOLD III and IV, presented lower bone formation rate than GOLD I and II (0.028 ± 0.009 versus 0.016+ 0.011 µm(3)/µm(2)/day; p = 04). This is the first evaluation of bone microstructure and remodeling in COPD. The skeletal abnormalities seen in cancellous and cortical bone provide an explanation for the high prevalence of vertebral fractures in this disease.

Correlates of osteoporosis in chronic obstructive pulmonary disease: An underestimated systemic component

RATIONALE

Chronic obstructive pulmonary disease (COPD) patients are at increased risk of osteoporosis. Osteoporosis is under diagnosed and under treated in these patients and the underlying mechanisms remain unclear. To date, screening recommendations for osteoporosis in COPD patients are not available.

OBJECTIVES

To examine the prevalence of drug treatment of bone abnormalities as well as the clinical determinants of osteoporosis in COPD.

METHODS

COPD patients (n=554) consecutively entering pulmonary rehabilitation were included in this cross-sectional study. Medical history, current medication use, smoking status, lung function, bone mineral density, body composition and other clinical characteristics were assessed before entering pulmonary rehabilitation. Univariate- and multivariate multinomial logistic regression analyses were used to determine correlates of osteoporosis.

MAIN RESULTS

Twenty-one percent of patients had osteoporosis and 41% had osteopenia. Osteoporosis was pharmacologically under treated (82% of osteoporotic patients were not receiving bone medication). Independent predictors of osteoporosis were cachexia (OR: 12.1; 95%CI: 4.5-32.7; p<0.001), age between 55 and 65 years (OR: 6.0; 95%CI: 2.2-16.3; p<0.001) and over 65 years (OR: 11.7; 95%CI: 4.1-33.1; p=<0.001). Overweight (OR: 0.1; 95%CI: 0.05-0.4; p=0.001) and obesity (OR: 0.78; 95%CI: 0.02-0.4; p=0.002) showed a substantial protective effect.

CONCLUSIONS

The majority of COPD patients with osteoporosis entering pulmonary rehabilitation did not receive pharmacological treatment for osteoporosis. Cachectic COPD patients should be screened for osteoporosis, especially when over 55 years of age.

Prevalence and predictors of vertebral fracture in patients with chronic obstructive pulmonary disease

OBJECTIVES

Patients with COPD are at risk for osteoporosis-related vertebral compression fractures (VCF) which predispose to more fractures and worsening pulmonary function. Our objectives were to: 1 document VCF prevalence in COPD patients; and 2 determine the independent correlates of VCF.

METHODS

From 2004-2006, we prospectively recruited consecutive consenting COPD patients presenting with acute exacerbation at three Canadian Emergency Departments (ED). We collected clinical and pulmonary function data. Primary outcome was radiologist documented VCF on chest radiograph. Multivariable logistic regression was used for all adjusted analyses.

RESULTS

Overall, 245 patients were studied; 37% were >or=75 years and 44% were women. Prevalence of VCF documented by chest radiograph was 22 of 245 (9%; 95%CI 6-13%). Almost half (10 of 22 [43%]) of VCF patients were not treated for osteoporosis and all 10 received oral steroids. Compared to patients without fractures, those with VCF were older (p=0.014), had COPD of longer duration (p=0.09) and greater severity (mean FEV(1) 0.9 vs 1.1L; p=0.05), and had lower body mass index [BMI] (median 26 vs 28; p=0.01). Across BMI quartiles (from heaviest [median 37] to lightest [median 21]) the prevalence of VCF progressively increased (2%, 8%, 10%, 21%; p<0.001). In analyses adjusted for age, sex, and COPD duration, the only independent correlate of VCF was BMI: VCF increased as BMI decreased from heaviest (OR=1) to lightest (OR=11.0) quartiles (p=0.025).

CONCLUSIONS

Almost one-tenth of COPD patients presenting with acute exacerbation have chest radiographs documenting VCF. About half of patients with VCF were not treated for osteoporosis, but all were started on oral steroids. Our findings suggest chest radiograph reports may represent an important case-finding tool for VCF, particularly in underweight patients with COPD.

Targeted treatment in COPD: a multi-system approach for a multi-system disease

Chronic obstructive pulmonary disease is a varied condition when examined from a number of different perspectives including factors which influence disease development, pathological process and clinical features. There may be a complex interaction between the degree by which each of these processes influences the development of COPD and the subsequent clinical phenotype with which the patient presents. The varied host response and subsequent clinical phenotype has generated much interest in recent years. It is possible that failure of treatment to impact on mortality and reverse the disease process is because of the heterogeneous nature of the condition. Identification and targeted treatment of clinical and pathological phenotypes within the broad spectrum of COPD may therefore improve outcome. This article will review previous work which has attempted to phenotype COPD and identify if specific treatment for these phenotypes has been shown to be of benefit. It will examine the work on pathological processes and clinical manifestations, both pulmonary and systemic, and will focus on pharmacological therapies.

Vertebral fractures in patients with chronic obstructive pulmonary disease: the EOLO Study

SUMMARY

This study aimed to evaluate the prevalence of vertebral fractures to investigate the determinants of vertebral fracture risk in patients with COPD. The risk of vertebral fractures is strictly related to the severity of the disease. The use of glucocorticoids and the presence of low values of quantitative ultrasound (QUS) may represent additional risk factors.

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) appears to be associated with osteoporosis. Our study aimed to evaluate the prevalence of vertebral fractures and to investigate the main determinants of vertebral fracture risk in patients with COPD.

METHODS

In 3,030 ambulatory COPD patients (1,778 men and 1,262 women) aged 50 years or over, we evaluated: COPD severity, presence of vertebral fractures on lateral chest X-ray and bone status by using a quantitative ultrasound device.

RESULTS

In men there was a strong association between COPD severity and fractures (p < 0.001), conversely in women the association between COPD severity and fractures was at limit (p = 0.049). In men, but not in women, glucocorticoid treatment was significantly associated with vertebral fractures. The patients with high or moderate risk of osteoporosis presented an increased risk of vertebral fracture (OR 2.71; 95% CI 2.04-3.60 and OR 1.54; 95% CI 1.26-1.88, respectively). Logistic regression analysis showed that COPD severity and glucocorticoid treatment, both inhaled and oral, were associated with increased risk of vertebral fractures.

CONCLUSION

In COPD patients the risk of vertebral fractures is strictly related to the severity of the disease. The use of glucocorticoids and reduced QUS at calcaneous may represent additional risk factors.

Comorbidities in chronic obstructive pulmonary disease

Comorbidities such as cardiac disease, diabetes mellitus, hypertension, osteoporosis, and psychological disorders are commonly reported in patients with chronic obstructive pulmonary disease (COPD) but with great variability in reported prevalence. Tobacco smoking is a risk factor for many of these comorbidities as well as for COPD, making it difficult to draw conclusions about the relationship between COPD and these comorbidities. However, recent large epidemiologic studies have confirmed the independent detrimental effects of these comorbidities on patients with COPD. On the other hand, many of these comorbidities are now considered to be part of the commonly prevalent nonpulmonary sequelae of COPD that are relevant not only to the understanding of the real burden of COPD but also to the development of effective management strategies.

Other systemic manifestations of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) no longer is regarded simply as a disease of the lungs and airways. There is growing awareness of the multisystemic nature of this disease. Research has shown increased levels of systemic inflammation and cardiovascular, neurologic, psychiatric, and endocrine system dysfunction associated with COPD. Skeletal muscle dysfunction associated with COPD is discussed in the article by Schols in this issue of Clinics in Chest Medicine. In this article, other systemic manifestations of COPD are discussed. Although this field is expanding rapidly, this article focuses on recent advances and reviews.

The prevalence of osteoporosis in patients with chronic obstructive pulmonary disease: a cross sectional study

Chronic obstructive pulmonary disease (COPD) is a complex disease, where the initial symptoms are often cough as a result of excessive mucus production and dyspnea. With disease progression several other symptoms may develop, and patients with moderate to severe COPD have often multiorganic disease with severely impaired respiratory dysfunction, decreased physical activity, right ventricular failure of the heart, and a decreased quality of life. In addition osteoporosis might develop possibly due to a number of factors related to the disease. We wanted to investigate the prevalence of osteoporosis in a population of patients with severe COPD as well as to correlate the use of glucocorticoid treatment to the occurrence of osteoporosis in this population. Outpatients from the respiratory unit with COPD, a history of forced expiratory volume in 1s (FEV1) less than 1.3 L, with FEV1% pred. ranging from 17.3% to 45.3% (mean 31.4%, standard deviation (sd) 7.3%). Patients between 50 and 70 years were included. Other causes of osteoporosis were excluded before inclusion. At study entry spirometry, X-ray of the spine (to evaluate presence of vertebral fractures), and bone mineral density of lumbar spine and hip were performed. Of 181 patients invited by mail, 62 patients were included (46 females and 16 males). All had symptoms of COPD such as exertional dyspnea, productive cough, limitations in physical activity etc. The mean FEV1 was 0.90 L (sd: 0.43 L) and the mean FEV1% pred. of 32.6% (sd: 14.1%). All had sufficient daily intake of calcium and vitamin D. In 15 patients, X-ray revealed compression fractures previously not diagnosed. Bone density measurements showed osteoporosis in 22 patients and osteopenia in 16. In total, 26 of the COPD patients were osteoporotic as evaluated from both X-ray and bone density determinations. Thus 68% of the participants had osteoporosis or osteopenia, but glucocorticoid use alone could not explain the increased prevalence of osteoporosis. A large fraction of these needed treatment for severe osteoporosis in order to prevent further bone loss and to reduce future risk of osteoporotic fractures. Thus, there is a significant need to screen patients with COPD to select the individuals in risk of fracture and to initiate prophylaxis or treatment for the disease.

Treatment of chronic obstructive pulmonary disease in older adults

This article summarizes some distinctive features of chronic obstructive pulmonary disease in the elderly and the ensuing diagnostic and therapeutic needs. It focuses on atypical presentation, systemic effects of the disease and comorbid conditions. The role of nonpharmacological measures, such as rehabilitation, physical exercise and nutritional support, is discussed. Finally, the author emphasizes that a comprehensive geriatric approach should guide the planning of therapy and monitoring of its efficacy.

[Primary and secondary osteoporosis. The important role of internal medicine in its differential diagnosis]

Bone metabolism as an important part of internal medicine is covered by endocrinologists, rheumatologists and nephrologists. Primary osteoporosis is an inheritable metabolic bone disease, which can be strongly modified by lifestyle, ageing and underlying diseases. Chronic inflammatory diseases, disorders of metabolism and nutritional deficits enhance the risk. Secondary osteoporosis is caused by endocrinological disorders and drugs such as glucocorticoids. It is the task of internists to clinically recognise and diagnose prominent individual risk factors for primary osteoporosis and underlying diseases for secondary osteoporosis. The key competence of internal medicine in metabolism, hormone-related disorders, malignant diseases and in handling complex medical treatment modalities represents an indispensable segment of an interdisciplinary network approach in patient care, research and teaching. This network includes orthopaedic surgery, paediatrics and gynaecology in addition to other specialties.

Bone mineral density in lymphangioleiomyomatosis

Estrogen deficiency and pulmonary diseases are associated with bone mineral density (BMD) loss. Lymphangioleiomyomatosis (LAM), a disorder affecting women that is characterized by cystic lung lesions, is frequently treated with antiestrogen therapy, i.e., progesterone and/or oophorectomy. Therefore, we evaluated BMD yearly in 211 LAM patients to determine the prevalence of BMD abnormalities, whether antiestrogen therapy decreased BMD, and if treatment with bisphosphonates prevented bone loss. Abnormal BMD was found in 70% of the patients and correlated with severity of lung disease and age. Greater severity of lung disease, menopause, and oophorectomy were associated with greater decline in BMD. After adjusting for differences in initial lung function and BMD, we found similar rates of BMD decline in progesterone-treated (n = 122) and untreated patients (n = 89). After similar adjustments, we found that bisphosphonate-treated patients (n = 98) had lower rates of decline in lumbar spine BMD (-0.004 +/- 0.003 vs. -0.015 +/- 0.003 gm/cm(2), p = 0.036) and T-scores (-0.050 +/- 0.041 vs. -0.191 +/- 0.041, p < 0.001) than untreated patients (n = 113). We conclude that abnormal BMD was frequent in LAM. Progesterone therapy was not associated with changes in BMD; bisphosphonate therapy was associated with lower rates of bone loss. We recommend systematic evaluation of BMD and early treatment with bisphosphonates for patients with LAM.

Categorizing asthma severity: an overview of national guidelines

Asthma is an inflammatory disease of the airways associated with intermittent episodes of bronchospasm. Corticosteroids are the most effective anti-inflammatory class of medication currently available for the treatment of asthma. However, as higher doses of inhaled corticosteroids are used the risks of systemic exposure and side effects will correspondingly increase. Justification of the benefits from higher doses of inhaled corticosteroids can only be made if patients with more severe asthma can be identified. Methods to categorize asthma severity have been introduced in various national asthma management guidelines. Unfortunately, there are substantial conceptual and practical differences among these recommended approaches to asthma severity categorization. Furthermore, these recommended approaches suffer from a focus on features of asthma control, such as symptoms, short-acting beta-agonist use, and lung function rather than actual measures of asthma severity that would encompass markers of airway inflammation. Without the endpoints necessary to assess airway inflammation, current recommendations for asthma severity categorization may lead to systematic under dosing of appropriate anti-inflammatory therapy with subsequent perpetuation of the asthma exacerbation cycle.