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

The potential therapeutic role of curcumin in osteoporosis treatment: based on multiple signaling pathways

Osteoporosis is a common chronic metabolic bone disease caused by disturbances in normal bone metabolism and an imbalance between osteoblasts and osteoclasts. Osteoporosis is characterized by a decrease in bone mass and bone density, leading to increased bone fragility. Osteoporosis is usually treated with medications and surgical methods, but these methods often produce certain side effects. Therefore, the use of traditional herbal ingredients for the treatment of osteoporosis has become a focus of attention and a hot topic in recent years. Curcumin, widely distributed among herbs such as turmeric, tulip, and curcuma longa, contains phenolic, terpenoid, and flavonoid components. Modern pharmacological studies have confirmed that curcumin has a variety of functions including antioxidant and anti-inflammatory properties. In addition, curcumin positively regulates the differentiation and promotes the proliferation of osteoblasts, which play a crucial role in bone formation. Multiple studies have shown that curcumin is effective in the treatment of osteoporosis as it interacts with a variety of signaling pathway targets, thereby interfering with the formation of osteoblasts and osteoclasts and regulating the development of osteoporosis. This review summarized the key signaling pathways and their mechanisms of action of curcumin in the prevention and treatment of osteoporosis and analyzed their characteristics and their relationship with osteoporosis and curcumin. This not only proves the medicinal value of curcumin as a traditional herbal ingredient but also further elucidates the molecular mechanism of curcumin's anti-osteoporosis effect, providing new perspectives for the prevention and treatment of osteoporosis through multiple pathways.

Impact of urinary calcium excretion on kidney, bone, and cardiovascular systems in patients with bone biopsy proven osteoporosis: a longitudinal long-term follow-up study

The impact of urine calcium on kidney, bone, and cardiovascular systems in osteoporosis is not well-known. In this 7-year-follow-up study, high urine calcium did not affect kidney function but increased risk of kidney stones, while low urine calcium increased cardiovascular diseases. Maintaining normal urine calcium is beneficial for bone health.

PURPOSE

Hypercalciuria is common in patients with osteoporosis. However, the long-term effect of urinary calcium excretion (UCaE) on patients' health is not well-examined. The current study aims to assess the impact of UCaE on kidney, bone, and cardiovascular outcomes in patients with bone biopsy proven osteoporosis.

METHODS

Longitudinal study of all patients with osteoporosis who underwent bone biopsy and 24-h urine collection between 2008 and 2015 in the University of Kentucky. DXA scans, serum markers, kidney function, and cardiovascular events were recorded until last clinic visit in 2021. Exclusion criteria were secondary osteoporosis or conditions that might substantially impact UCaE. The significant results in univariate analysis were confirmed in multi-variable regression models involving clinically important covariates that might impact patients' outcomes.

RESULTS

Study included 230 patients with mean follow-up of 7.2 ± 2.9 years. The mean age was 61 years, and the mean eGFR at baseline was 85 ± 19 ml/min/1.73 m². Low bone turnover (LBT) was present in 57% and high bone turnover (HBT) in 43% of patients. Hypercalciuria was found in one-third of patients with no difference between LTB and HTB. UCaE correlated positively with eGFR but did not affect the rate of eGFR decline over time. Higher UCaE predicted kidney stones development. We observed U-shaped effect of UCaE on bone health. Hypercalciuria predicted loss of BMD at all sites, but also hypocalciuria was associated with higher loss in total hip BMD. Upper limb fractures were the most observed fractures, and their incidence was higher in patients with hyper- or hypo-calciuria. Lower UCaE independently predicted development of major adverse cardiac events (MACE) and cardiovascular disease (CVD).

CONCLUSION

UCaE correlated with eGFR but it did not affect the change of eGFR over time. Patients with normal UCaE had lower incidence of upper limb fractures and less reduction in BMD. Low UCaE predicted MACE and CVD.

An Evidence-Based Review: The Effects of Malaysian Traditional Herbs on Osteoporotic Rat Models

Osteoporosis is considered a silent disease, the early symptoms of which often go unrecognised. Osteoporosis causes bone loss, reduces mineralised density, and inevitably leads to bone fracture. Hormonal deficiencies due to aging or drug induction are also frequently attributed to osteoporosis. Nevertheless, the phytochemical content of natural plants has been proven to significantly reduce osteoporotic conditions. A systematic review was conducted by this study to identify research specifically on the effects of Malaysian herbs such as Piper sarmentosum, Eurycoma longifolia and Labisia pumila on osteoporotic bone changes. This review consisted of a comprehensive search of five databases for the effects of specific herbs on osteoporotic bone change. These databases were Web of Science (WOS), Medline, Scopus, ScienceDirect and PubMed. The articles were selected throughout the years, were limited to the English language and fully documented. Duplication, irrelevant titles, different herbs and in vitro studies were excluded, including those that are not original research papers. A total of 399 potential studies were identified, but only 21 samples were accepted based on the inclusion and exclusion criteria. Six of the twenty one studies were on Piper sarmentosum, six on Eurycoma longifolia, and the remaining nine studies were on Labisia pumila. Overall, in three of the studies a glucocorticoid-induced model was used, while in 12 of the studies an ovariectomised model was used, and for the other six studies an orchidectomised model was used as the osteoporotic model. All of the studies reported varied results based on the type of herbs used, but in comparison to Eurycoma longifolia, Piper sarmentosum and Labisia pumila recorded better anti-osteoporotic effects, while the majority of studies on Eurycoma longifolia were unable to preserve bone strength.

Understanding and managing secondary osteoporosis

INTRODUCTION

The term secondary osteoporosis (SO) identifies a reduction of bone mass related to a well-established disease or pharmacological agent. The identification of the underlying disease often represents a challenging situation in clinical practice.

AREAS COVERED

The prevalence of SO in the real world may vary, ranging from 17% to 80%; therefore, search for a form of SO represents a pillar when evaluating patients with osteoporosis. Guidelines for treatment of specific secondary forms of osteoporosis, such as glucocorticoid-induced osteoporosis, have been published even though often neglected in clinical practice. For the majority of SO, there are currently no specific guidelines concerning treatment with only few trials showing the effect of bone-active drugs on fracture risk reduction.

EXPERT OPINION

Healthcare professionals should be aware of the secondary forms of osteoporosis, in particular when the reason for reduced skeletal resistance is uncertain or when bone mineral density results are unsatisfactory in a patient compliant to therapy. In a few cases (such as, for example: no response to therapy, better classification of bone involvement in patients with kidney failure, suspicion of rare metabolic bone disease) bone biopsy is needed to investigate the patient. This review highlights recent advances in understanding and managing SO.

Secondary osteoporosis and metabolic bone disease in patients 50 years and older with osteoporosis or with a recent clinical fracture: a clinical perspective

PURPOSE OF REVIEW

The purpose of this review is to provide guidance to clinicians about which laboratory tests should be performed in patients with osteoporosis or with a recent fracture.

RECENT FINDINGS

Newly diagnosed secondary osteoporosis and other metabolic bone diseases (SECOB) have been found in 5-48% of patients with osteoporosis. In patients with a recent fracture, new SECOB is found in 10-47% of patients with osteoporosis, and in 26-51% if all patients with a fracture regardless of bone mineral density (BMD) are screened. More than one SECOB can be found in the same patient, even when they have already known SECOB. In primary hyperparathyroidism, hyperthyroidism, hypercortisolism, and multiple myeloma, both SECOB and its treatment have an impact on BMD and fractures. For other SECOBs, no treatment is available, or there are no data about the effect of treatment of the SECOB on BMD and fractures.

SUMMARY

We recommend performing the following tests in all patients with osteoporosis or a recent clinical fracture: calcium, phosphate, creatinine, albumin, erythrocyte sedimentation rate in all patients, 24 h urine calcium in men and serum testosterone in men less than 70 years. On indication, additional tests can be performed.

Hospital care for primary hyperparathyroidism in Italy: a 6-year register-based study

OBJECTIVE

Primary hyperparathyroidism (PHPT) is one of the most frequently diagnosed endocrine disorders, but few studies have focused on hospital management of the disease in Europe. We investigated the frequency of hospital admission for diagnosis and surgical treatment of PHPT in Italy.

DESIGN

A retrospective study was conducted for investigating the hospital care for PHPT in Italy.

METHODS

We retrieved data from the 'Record of Hospital Discharge' of the Italian Health Ministry, from 2006 to 2011, and analyzed the codes corresponding to PHPT-related diagnoses and surgical procedures.

RESULTS

Overall, 46 275 hospitalization episodes for PHPT were identified during the entire period (69% in women and 31% in men; mean age 63.3±39.8 years). Patients' mean age significantly increased during the years (P<0.001). The mean length of stay was 8.2±10.5 days (28% of the episodes requiring <3 days of stay). Admissions for surgical procedures were 12 457 accounting for 26.9% of the total hospitalizations. There was a trend to a significant increase in the percentage of surgery (P<0.05). The mean hospitalization rate for PHPT was 12.9/100 000 inhabitants per year and the trend showed a significant decrease during the period of 2006-2011 (P<0.0001). The mean hospitalization rate for PHPT surgery was 3.65/100 000 per year, which significantly increased over time (P<0.001).

CONCLUSIONS

PHPT considerably influences the Italian Hospital healthcare system. We observed a tendency to a decrease in the frequency of hospitalization during the period of 2006-2011, most probably because of economic issues, a concomitant increased age of patients, and, interestingly, also a progressive increase in the percentage of surgical treatment among patients admitted for PHPT.

Osteoporosis in men: a review

Osteoporosis and consequent fracture are not limited to postmenopausal women. There is increasing attention being paid to osteoporosis in older men. Men suffer osteoporotic fractures about 10 years later in life than women, but life expectancy is increasing faster in men than women. Thus, men are living long enough to fracture, and when they do the consequences are greater than in women, with men having about twice the 1-year fatality rate after hip fracture, compared to women. Men at high risk for fracture include those men who have already had a fragility fracture, men on oral glucocorticoids or those men being treated for prostate cancer with androgen deprivation therapy. Beyond these high risk men, there are many other risk factors and secondary causes of osteoporosis in men. Evaluation includes careful history and physical examination to reveal potential secondary causes, including many medications, a short list of laboratory tests, and bone mineral density testing by dual energy X-ray absorptiometry (DXA) of spine and hip. Recently, international organizations have advocated a single normative database for interpreting DXA testing in men and women. The consequences of this change need to be determined. There are several choices of therapy for osteoporosis in men, with most fracture reduction estimation based on studies in women.

Adherence to osteoporosis regimens among men and analysis of risk factors of poor compliance: a 2-year analytical review

BACKGROUND

To investigate adherence and patient-specific factors associated with poor compliance with osteoporosis regimens among men.

METHODS

In this retrospective chart review study, we collected data on male patients with osteoporosis treated in accordance with therapeutic recommendations. Adherence was determined by the compliance and persistence of those patients who had been dispensed an osteoporosis regimen after an index prescription. All osteoporosis regimens were considered equivalent for the purpose of investigating adherence.

RESULTS

The prescriptions of 333 males met the inclusion criteria for data collection. The mean age was 68.6 ± 10.4 years. The median medication possession ratio (MPR, %) at years 1 and 2 was 90.1% (interquartile range (IQR) 19-100) and 53.7% (IQR 10.4-100), respectively; 52.3% of male patients at year 1 and 37.5% at year 2 had good compliance (defined as a MPR≧80%). The 1- and 2-year persistence rates were 45.9% and 30.0%, respectively. Patient-specific factors associated with poor compliance (MPR < 80%) during year 1 were first prescriptions given by orthopedists (odds ratio (OR) = 2.67; 95% confidence interval (CI) = 1.58-4.53; adjusted OR = 2.30, 95% CI = 1.26-4.22, p = 0.007). Male patients with rheumatoid arthritis (RA) (OR = 0.22, 95% CI = 0.06-0.78, adjusted OR = 0.19, 95% CI = 0.04-0.81, p = 0.025) and baseline bone mineral density (BMD) measurements (OR = 0.52, 95% CI = 0.32-0.85; adjusted OR = 0.51; 95% CI = 0.28-0.93, p = 0.029) were less likely to have poor compliance.

CONCLUSIONS

Adherence to osteoporosis regimens in males was suboptimal in our study. Poor compliance was more likely in prescription of the first anti-osteoporotic regimen by an orthopedist. Men with RA and BMD measurements before therapy had a lower risk of non-adherence. Healthcare professionals need to target patients with specific factors to improve adherence to osteoporotic regimens.

Prevalence of subclinical contributors to low bone mineral density and/or fragility fracture

OBJECTIVE

The prevalence of subclinical contributors to low bone mineral density (BMD) and/or fragility fracture is debated. We evaluated the prevalence of subclinical contributors to low BMD and/or fragility fracture in the presence of normal 25-hydroxyvitamin D (25OHVitD) levels.

DESIGN

Prospective observational study.

METHODS

Among 1095 consecutive outpatients evaluated for low BMD and/or fragility fractures, 602 (563 females, age 65.4±10.0 years) with apparent primary osteoporosis were enrolled. A general chemistry profile, phosphate, 25OHVitD, cortisol after 1-mg overnight dexamethasone suppression test, antitissue transglutaminase and endomysial antibodies and testosterone (in males) were performed. Serum and urinary calcium and parathyroid hormone levels were also evaluated after 25OHVitD levels normalization. Vertebral deformities were assessed by radiograph.

RESULTS

In total, 70.8% of patients had low 25OHVitD levels. Additional subclinical contributors to low BMD and/or fragility fracture were diagnosed in 45% of patients, with idiopathic hypercalciuria (IH, 34.1%) and primary hyperparathyroidism (PHPT, 4.5%) being the most frequent contributors, apart from hypovitaminosis D. Furthermore, 33.2% of IH and 18.5% of PHPT patients were diagnosed only after 25OHVitD levels normalization. The subclinical contributors to low BMD and/or fragility fracture besides hypovitaminosis D were associated inversely with age (odds ratio (OR) 1.02, 95% CI 1-1.04, P=0.04) and BMI (OR 1.1, 95% CI 1.05-1.17, P=0.0001) and directly with fragility fractures (OR 1.89, 95% CI 1.31-2.73, P=0.001), regardless of BMD.

CONCLUSIONS

Subclinical contributors to low BMD and/or fragility fracture besides hypovitaminosis D are present in more than 40% of the subjects with apparent primary osteoporosis. Hypovitaminosis D masks a substantial proportion of IH and PHPT patients.

Osteoporosis in men: recent progress

As osteoporosis in men has been recognized as an important clinical problem, new information is being accumulated on its scope, pathophysiology, evaluation, and treatment. Fracture risk calculators, such as FRAX, identify a large proportion of the older male population to be at heightened risk for fracture. The classification of osteoporosis into primary and secondary forms, while still useful, is affected by the fact that many men have multiple contributing factors to their fracture risk. The role of sex steroids is being better defined as other risk factors for fracture are delineated. As longevity continues to increase in men and until osteoporotic fracture is truly recognized as a potentially fatal disorder, many men will be undiagnosed and untreated. Two recent studies provide more evidence that treatments which decrease fracture risk in women do the same in men. With the publication of guidelines and increasing strength of evidence for treatment efficacy, it is hoped that more men will be evaluated and treated for this often neglected disorder.

An epidemiological analysis of the incidence of osteoporosis and osteoporosis-related fractures among the Saudi Arabian population

BACKGROUND AND OBJECTIVES

Osteoporosis is common in Saudi Arabia and the burden of management in an aging population will increase in coming decades. There is still no national policy nor consensus on screening for this silent disease. The objective of this analysis was to determine from the published data the prevalence of osteopenia and osteoporosis in Saudi Arabians, the prevalence of secondary osteoporosis, and the prevalence of osteoporosis-related fractures (ORF). We also sought to determine the best age to begin and best modality for screening.

METHODS

Data Sources were MEDLINE (1966 to May 2011), EMBASE (1991 to May 2011), the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (1952 to May 2011), and the Science Citation Index (1966 to May 2011), published data from the Saudi Medical Journal (1985-2011) and Annals of Saudi Medicine (1985-2011). We selected English-language articles with at least 100 Saudi individuals. Two authors independently reviewed articles and abstracted data.

RESULTS

The authors identified 36 potentially relevant articles, of which 24 met the inclusion criteria. Of 5160 healthy women 50 to 79 years of age (mean, SD: 56.8 [2.7]), 36.6% (6.6%) were osteopenic and 34.0% (8.5%) were osteoporotic. In three studies on males (n=822), the prevalence of osteopenia was 46.3% and osteoporosis 30.7%. Males had a significantly higher frequency of osteopenia in comparison to females (P= < .001 95% CI < -0.0333), The mean age of the patients with secondary osteoporosis was 37.4 (13.5, 18-57) years, with the osteoporosis in 46.4% and osteopenia in 34.1%. In 5 studies of ORF, the incidence of vertebral fractures was between 20%-24%.

CONCLUSION

The currently available literature on Saudi Arabian population suggests that the ideal age for screening for low bone mass among the Saudi population should be earlier (55 years) than the >=65 years in Western countries. Both quatitative ultrasound and dual-energy x-ray absorptiometry could be used for screening. The relatively small number of studies on Saudi Arabians and the different machines used for diagnosis limited the authors ability make conclusions with surety.