Which Drug Next? Sequential Therapy for Osteoporosis

The proliferation of drugs with unique modes of action for treating osteoporosis has been most welcome. Fear of complications, even though rare, associated with long-term bisphosphonates (BPs) changed prescribing patterns. The BPs are stored in bone for years. Drugs not stored in bone; for example, abaloparatide, teriparatide, denosumab, and romosozumab have expanded our armamentarium for treating osteoporosis but have brought new challenges. Bone accrued during treatment with the last 3 drugs, and perhaps abaloparatide, is lost rapidly after their withdrawal due to rebound increase in bone resorption. Treatment with these drugs must be followed by administration of an antiresorptive agent. The article by Kendler et al. (1) in this issue of JCEM reports alendronate preserves bone accrued during administration of denosumab.

Spinal extension exercises prevent natural progression of kyphosis

The angle of kyphosis increases with age with the most rapid increase occurring between 50 and 60 years. The progression of kyphosis was prevented in women ages 50-59 years who performed extension exercises three times a week for one year.

INTRODUCTION

The purpose of this study was to (1) measure the progression of the angle of kyphosis with age and (2) determine whether spinal extension exercises prevent progression of hyperkyphosis in women 50-59 years of age.

METHOD

Part 1: Cross-sectional study of changes in posture with age, determined by measuring spinal curves in 250 women 30-79 years of age. Part 2: One-year prospective, descriptive analysis of the effect of extension exercises on posture in women 50-59 years of age. Depth of the cervical curve (CD), area under the thoracic curve (TA), and height were measured using a device developed at Kansas University Medical Center. Changes in CD and TA in women compliant with extension exercises were compared to those in non-compliant women.

RESULTS

Kyphosis increases with age in healthy women, with the greatest difference observed between women 50 and 59 years of age. The progression of kyphosis was greater in women who did not perform extension exercises compared to those who performed extension exercises three times per week for 1 year. The difference in change in CD and TA between the two groups was highly significant (CD p = .0001, TA p = .0001).

CONCLUSIONS

Kyphosis increases with age in healthy women. In this study the greatest difference in the angle of kyphosis was observed between the fifth and sixth decade. Exercises which strengthen the extensor muscles of the spine can delay the progression of hyperkyphosis in the group included in this study, i.e., women 50-59 years of age.

Osteoporosis associated with excess glucocorticoids

Excess glucocorticoids, whether endogenous or exogenous, can cause osteoporosis and fractures. Even low doses of oral glucocorticoids and mild endogenous hypercortisolism may be associated with bone loss. Patients treated with glucocorticoids, however, often are not evaluated and treated for this problem. Patients on chronic glucocorticoids or initiating these drugs should have their bone density measured and appropriate laboratory studies. They should be treated with adequate calcium and vitamin D, and antiresorptive therapy (particularly bisphosphonates) should be considered.

Risedronate therapy prevents corticosteroid-induced bone loss: a twelve-month, multicenter, randomized, double-blind, placebo-controlled, parallel-group study

OBJECTIVE

Risedronate, a new pyridinyl bisphosphonate, is a potent antiresorptive bone agent. This study examines the safety and efficacy of daily, oral risedronate therapy for the prevention of corticosteroid-induced bone loss.

METHODS

This multicenter, randomized, double-blind, placebo-controlled, parallel-group study was conducted in 224 men and women who were initiating long-term corticosteroid treatment. Patients received either risedronate (2.5 mg or 5 mg) or placebo daily for 12 months. Each patient also received 500 mg of elemental calcium daily. The primary outcome measure was the percentage of change in lumbar spine bone mineral density (BMD). Secondary measures included proximal femur BMD and incidence of vertebral fractures.

RESULTS

After 12 months, the lumbar spine BMD (mean +/- SEM) did not change significantly compared with baseline in the 5-mg (0.6 +/- 0.5%) or the 2.5-mg (-0.1 +/- 0.7%) risedronate groups, while it decreased in the placebo group (-2.8 +/- 0.5%; P < 0.05). The mean differences in BMD between the 5-mg risedronate and the placebo groups were 3.8 +/- 0.8% at the lumbar spine (P < 0.001), 4.1 +/- 1.0% at the femoral neck (P < 0.001), and 4.6 +/- 0.8% at the femoral trochanter (P < 0.001). A trend toward a decrease in the incidence of vertebral fracture was observed in the 5-mg risedronate group compared with the placebo group (5.7% versus 17.3%; P = 0.072). Risedronate was well tolerated, and the incidence of upper gastrointestinal adverse events was comparable among the 3 groups.

CONCLUSION

Risedronate therapy prevents bone loss in patients initiating long-term corticosteroid treatment.

Risedronate therapy prevents corticosteroid-induced bone loss: a twelve-month, multicenter, randomized, double-blind, placebo-controlled, parallel-group study

OBJECTIVE

Risedronate, a new pyridinyl bisphosphonate, is a potent antiresorptive bone agent. This study examines the safety and efficacy of daily, oral risedronate therapy for the prevention of corticosteroid-induced bone loss.

METHODS

This multicenter, randomized, double-blind, placebo-controlled, parallel-group study was conducted in 224 men and women who were initiating long-term corticosteroid treatment. Patients received either risedronate (2.5 mg or 5 mg) or placebo daily for 12 months. Each patient also received 500 mg of elemental calcium daily. The primary outcome measure was the percentage of change in lumbar spine bone mineral density (BMD). Secondary measures included proximal femur BMD and incidence of vertebral fractures.

RESULTS

After 12 months, the lumbar spine BMD (mean +/- SEM) did not change significantly compared with baseline in the 5-mg (0.6 +/- 0.5%) or the 2.5-mg (-0.1 +/- 0.7%) risedronate groups, while it decreased in the placebo group (-2.8 +/- 0.5%; P < 0.05). The mean differences in BMD between the 5-mg risedronate and the placebo groups were 3.8 +/- 0.8% at the lumbar spine (P < 0.001), 4.1 +/- 1.0% at the femoral neck (P < 0.001), and 4.6 +/- 0.8% at the femoral trochanter (P < 0.001). A trend toward a decrease in the incidence of vertebral fracture was observed in the 5-mg risedronate group compared with the placebo group (5.7% versus 17.3%; P = 0.072). Risedronate was well tolerated, and the incidence of upper gastrointestinal adverse events was comparable among the 3 groups.

CONCLUSION

Risedronate therapy prevents bone loss in patients initiating long-term corticosteroid treatment.

Long-term low ascorbic acid intake reduces bone mass in guinea pigs

The effect of long-term (1 y) low to excess ascorbic acid (AA) intake on bone mass was evaluated using guinea pigs that were 12-14 d old at the start of the experiment. Dietary AA was low (0.15 g/ kg diet) (n = 7), normal (0.50 g/kg) (n = 8) or excess (10 g/kg) (n = 8). After 12 mo, total body bone mineral density (BMD, mg/cm2) and bone mineral content (BMC, g) were determined by dual energy X-ray absorptiometry. Histomorphometric analysis of the cancellous bone of the proximal tibial metaphysis was completed after in vivo dual fluorochrome labeling. Total body BMD of the low AA group was 4.9% lower (P < 0.05), and total body BMC was 12.4% lower (P < 0.05) than in the normal AA group. Total body BMD and BMC were similar in normal and excess AA groups and in the low and excess AA groups. Histomorphometric analysis indicated significantly greater (P < 0.05) double-labeled bone surface, mineralizing surface, and bone formation rate in the low AA guinea pigs compared with the normal AA animals. Thus, there was greater bone turnover in the low AA group than in the normal AA guinea pigs. No differences in histomorphometric endpoints existed between the normal AA and excess AA groups. Long-term AA deficiency, during the period of rapid growth and slower phases of skeletal maturation, resulted in bone abnormalities in adult guinea pig skeletons. Long-term dietary AA excess caused no such abnormalities.

Scurvy results in decreased collagen synthesis and bone density in the guinea pig animal model

The effect of severe ascorbic acid deficiency on bone remodeling and collagen synthesis was evaluated in a 21 day experiment, using the scorbutic guinea pig model. Animals (n = 6-7/group) were assigned to one of three groups: scorbutic, pair-fed ascorbic acid-replete, or ad libitum ascorbic acid-replete groups. After 2 weeks, scorbutic animals started voluntarily decreasing food intake and losing weight. By day 19-21, at which time bone and tissue samples were collected and analyzed, scorbutic animals decreased food intake to 46% of usual and lost 9% body weight. Serum 25OHD3, 1,25(OH)2D3, calcium, and albumin were significantly lower (p < 0.05) in the scorbutic animals than in the other groups. Bone mineral density and bone mineral content of the proximal and central femur were significantly lower in the scorbutic group than in the other groups (p < 0.05). Morphometric analysis of tibia indicated significantly lower bone volume, fewer and thinner trabeculae, and a thinner growth plate in the scorbutic group, compared to the pair-fed and ad libitum groups (p < 0.05). Osteoclast surface was about 60% higher in the scorbutic group than in the pair-fed and ad libitum control groups (0.05 < p < 0.10). Mechanical strength of the femur and lumbar vertebral body tended to be lower when bone mass was altered in the same group. Collagen synthesis of articular cartilage and tendons was lower in the scorbutic group than in the pair-fed or ad libitum groups (p < 0.05). In conclusion, scurvy but not food restriction, per se, results in alterations in bone mass and tissue collagen synthesis.

Glucocorticoid-induced osteoporosis

Glucocorticoids are important in the management of rheumatic diseases. Bone loss is one of the most devastating side effects of glucocorticoids because they inhibit calcium transport, cause secondary hyperparathyroidism, hypogonadism, and impairment of osteoblast function. Efforts to control these side effects minimize bone loss.

Effects of nutritional supplementation on bone mineral status of children with rheumatic diseases receiving corticosteroid therapy

OBJECTIVE

Because children with rheumatic disease receiving longterm corticosteroids are at high risk for developing osteoporosis, we attempted to determine whether nutritional supplementation would improve bone status in this group of children.

METHODS

In a crossover design study, 10 corticosteroid treated children with rheumatic disease and osteoporosis received calcium and vitamin D supplementation for 6 months to determine their effect on bone density. They were then studied for 6 months without added nutrition supplements. The mean age was 13.1 years with a mean duration of disease of 4.2 years. Six patients had juvenile rheumatoid arthritis, 2 had systemic lupus erythematosus and 2 had mixed connective tissue disease. These children obtained a minimum of 1 g of calcium and 400 IU of vitamin D daily from diet and added supplements. Dual photon absorptiometry, laboratory and dietary data were obtained at baseline, 6 months, and one year.

RESULTS

Spinal bone density significantly improved with supplementation. Osteocalcin values remained low throughout the study.

CONCLUSION

Our results suggest some children with rheumatic disease receiving corticosteroids would benefit from calcium and vitamin D supplementation.

Vertebral compression fractures: how to manage pain, avoid disability

About 25% of U.S. women over age 50 will suffer one or more vertebral compression fractures related to osteoporosis. Vertebral fractures may be biconcave, anterior wedge, or crush deformities. A fracture is most often precipitated by putting a load on outstretched arms (eg, while raising a window). Back pain is usually incapacitating for a few weeks, then diminishes in severity but remains intense for 2 to 3 months. Acute complications include transient ileus, urinary retention, or (rarely) cord compression. Long-term effects include kyphosis, deconditioning, insomnia, and depression. Initial treatment includes bed rest, pain management with local and systemic analgesia, bracing to improve comfort, and patient reassurance. Long-term management includes spinal stretching exercises, walking, and treatment of underlying osteoporosis with calcitonin or estrogen in selected patients.

Estrogen and progesterone replacement therapy reduces glucocorticoid-induced bone loss

This is a retrospective study of 15 postmenopausal or amenorrheic women aged 34-78 years who had taken prednisone for 6-108 months and were followed for 1 year while continuing to take doses of 5-15 mg/day. A total of 8 patients were treated with 0.6256 mg Premarin daily for 25 days and 5 mg/day of medroxyprogesterone on days 15-25 (ERT, group 2); 7 were followed without ERT (group 1). A group of 17 women, matched for age, were randomly selected from our computerized data base to serve as a control group (group 3), and 10 women of similar age who were taking ERT only (group 4) were selected to compare the response to ERT to that of group 2. Bone density (BD) was measured in the lumbar spine baseline and at 1 year using dual-photon or dual-energy x-ray absorptiometry. Spine density did not change significantly during the year of observation in group 1. Although BD decreased in 5 of 7 patients, the change was not significant (-0.034 +/- 0.018 g/cm2, p = 0.10). In group 2 BD increased significantly, with 7 of 8 patients showing an increase (0.037 +/- 0.011 g/cm2, p = 0.008). BD did not change significantly in the control group (0.013 +/- 0.008 g/cm2, p = 0.16). Loss of bone from the spine was significantly greater in group 1 than in controls (p = 0.02), but changes in group 2 were similar to those in the control group (p = 0.66).(ABSTRACT TRUNCATED AT 250 WORDS)

Glucocorticoid-induced osteoporosis

The incidence of osteoporosis in patients receiving long-term glucocorticoid therapy is 30% to 50%. Trabecular bone is lost more rapidly than cortical. The cause of glucocorticoid-induced bone loss is multifactorial. Gastrointestinal absorption of calcium falls and urinary excretion rises, production of gonadal hormones decreases, and bone formation is inhibited in the presence of glucocorticoids. Bone loss can be minimized by using the lowest effective dose of a glucocorticoid with a short half-life, maintaining good nutritional status and physical activity, limiting sodium intake and giving a thiazide diuretic, maintaining serum 25-OHD at the upper limits of the normal range, giving estrogen replacement therapy to postmenopausal and amenorrheic women, and giving testosterone to men with low serum testosterone levels. The use of calcitonin or bisphosphonates should be considered.

New diagnoses in a specialty clinic: opportunities for consultants

The role consultants play in detecting disease coincidental to the reason for consultation is unclear. We sought to elucidate this function in the setting of a specialty clinic for osteoporosis. Making no specific attempt to screen for general conditions, we evaluated 760 women; any new diagnosis was found in the course of thoroughly examining the patient for osteoporosis. A total of 274 new diagnoses were counted, encompassing 68 conditions. There were 211 women (28%) in whom a new diagnosis was detected; a higher percentage of older women than younger women had a new diagnosis. A diagnosis severity grouping scheme was devised, groups C and D being those in which further evaluation was clearly indicated. The diagnoses in groups C and D accounted for 70% of all new diagnoses made, suggesting that trivial conditions were not overrepresented. The history and physical examination alone was responsible for 50% of the various conditions diagnosed and 64% of the total number of new diagnoses. The consultant has an excellent opportunity to detect disease while performing a specialty consultation.

Inhibition of mediator release in systemic mastocytosis is associated with reversal of bone changes

A 59-year-old male presented with systemic mastocytosis with extensive skeletal involvement resulting in vertebral compression fractures and bone pain. Histomorphometric analysis of bone revealed increased mast cells, elevated static parameters of bone resorption, and low bone formation. Serum calcium, phosphorus, and alkaline phosphatase were normal; however, serum 1,25-dihydroxyvitamin D3 and osteocalcin levels were low. Histamine levels in plasma and urine were elevated. Following therapy with ketotifen, the patient had resolution of bone pain along with decreased flushing and pruritus. Elevated plasma and urine histamine levels normalized, as did 1,25-dihydroxyvitamin D3 and osteocalcin levels. Indices of low bone formation improved on therapy. Eroded surfaces improved but remained elevated. This case is the first demonstration that bone symptoms and histomorphometric change in systemic mastocytosis are reversed with inhibition of mast cell degranulation. The role of mast cells and their products in bone metabolism is poorly understood, but the therapy of bone disease in systemic mastocytosis should include inhibition of the release of mast cell products along with the use of histamine antagonist.

Glucocorticoid-induced osteoporosis: pathogenesis and management

PURPOSE

To review the clinical picture, pathogenesis, and management of glucocorticoid-induced osteoporosis.

DATA IDENTIFICATION

Studies published since 1970 were identified from a MEDLINE search, articles accumulated by the authors, and through bibliographies of identified articles.

STUDY SELECTION

Information for review was taken from 160 of the more than 200 articles examined.

DATA EXTRACTION

Pertinent studies were selected; the relative strengths and weaknesses of these studies are discussed.

RESULTS OF DATA SYNTHESIS

Studies in tissue and organ cultures suggest that glucocorticoids have a direct effect on bone, causing inhibition of bone formation and enhancing bone resorption. Glucocorticoids decrease calcium absorption from the intestine and increase renal excretion. Osteoporosis occurs in at least 50% of persons who require long-term glucocorticoid therapy. Long-term trials of therapy for the prevention of glucocorticoid-induced osteoporosis have not been done, but reasonable recommendations include the use of a glucocorticoid with a short half-life in the lowest dose possible, maintenance of physical activity, adequate calcium and vitamin D intake, sodium restriction and use of thiazide diuretics, and gonadal hormone replacement. In refractory cases, the use of calcitonin, bisphosphonates, sodium fluoride, or anabolic steroids should be considered.

CONCLUSIONS

Osteoporosis is common in patients requiring long-term treatment with glucocorticoids. Careful attention to preventive management may minimize the severity of this serious complication.

Contributing diagnoses in osteoporosis. The value of a complete medical evaluation

Osteoporosis often occurs as a consequence of, or is accelerated by, many medical diseases, drug exposures, or other conditions. We called these conditions contributing diagnoses. Although technological advances permit the accurate measurement of bone density, identifying osteoporosis without searching for contributing diagnoses may result in remediable diseases being missed or in the initiation of inadvisable therapy. The value of comprehensive medical evaluation in conjunction with appropriate diagnostic studies was demonstrated in an osteoporosis referral center. We studied 300 consecutive persons who presented to an osteoporosis clinic. Using strict criteria, 180 patients (60%) had osteoporosis. Of these 180 patients, 83 (46%) had one or more contributing diagnosis, ie, a condition thought to accelerate bone loss. The largest single group was composed of persons with past or present exposure to glucocorticoids; the second largest group consisted of women who had undergone premature menopause. In all, 27 different contributing diagnoses were identified. Additionally, in 19 (11%) of the 180 patients with osteoporosis, a contributing diagnosis new to those patients was made. The evaluation of osteoporosis does not only entail measurement of bone density but must also take into consideration a patient's entire medical milieu.

Osteoporosis associated with mastocytosis confined to bone: report of two cases

Two women, ages 53 and 46, presented with multiple spontaneous vertebral fractures. Serum calcium, 25OHD, 1,25-(OH)2D, PTH, and 24-h urinary calcium were all normal. Bone mineral analysis (BMA) was performed at the junction of the distal third of the radius by single photon absorptiometry. BMA on Patient 1 was 0.68 g/cm2 and on Patient 2 was 0.58 g/cm2, with the normal being 0.70 g/cm2 and 0.77 g/cm2, respectively. In addition to vertebral fractures, x rays of Patient 2 revealed lytic lesions of the tibia and ulna. Bone biopsies revealed osteopenia associated with generalized eosinophilic fibromastocytosis and increased resorption without evidence of increased numbers of osteoclasts. There was no evidence of extraskeletal mast cell involvement. Our observations contribute to the increasing evidence that mast cells play a direct role in the etiology of osteoporosis in certain patients. Possible pathophysiologic mechanisms include mast cell release of heparin, histamine, prostaglandin D2 or other osteolytic substances.

Spinal compression fractures in osteoporotic women: patterns and relationship to hyperkyphosis

A prospective study of thoracic and lumbar spinal fracture distribution and its relationship to thoracic kyphosis was performed in 87 women with osteoporosis. Anterior wedge fractures were most commonly seen in the midthoracic spine and about the thoracolumbar junction, whereas central compression fractures were most common from the first to the fourth lumbar levels. Solitary wedge fractures did not occur above the seventh thoracic vertebra, suggesting that a cause other than osteoporosis must be suspected in any patient with an isolated high thoracic fracture. Analysis of the spinal radiographs obtained in an additional 16 women without osteoporosis revealed that both forms of fracture were unusual in this small group with normal spinal mineralization. The number of anterior wedge fractures in the thoracic spine correlated (r = .546) with the degree of thoracic kyphosis. However, 19% of the women with no thoracic fractures still had thoracic hyperkyphosis. The authors conclude that the hyperkyphosis of osteoporotic women is related to anterior compression fractures but also has contributing nonskeletal factors.

Influence of nutritional factors on calcium-regulating hormones and bone loss

The relationships between nutritional factors, calcium regulating hormones, and bone density were evaluated in three groups of normal subjects in rural southeast Kansas. Dietary intake of calcium (Ca), phosphorous (P), protein, and vitamin D; and serum 25OHD, Ca, P, parathyroid hormone (iPTH), and bone density (distal 1/3 radius) were measured in 29 elderly women, 35 elderly men, and 50 perimenopausal women. Measurements were repeated 5 years and 4 years later respectively in 16 elderly women and 15 elderly men. The r values for significant regression correlations for each group were as follows: perimenopausal: bone density and dietary Ca:P--r = .29, iPTH and 25OHD--r = -.38; elderly women: 25OHD and dietary Vitamin D(D)--r = .58, change in bone density (delta BD) and initial bone density (BDI)--r = -.71, delta BD and serum 25OHD--r = -.60, serum calcium and age--r = -.42; elderly men: Serum 25OHD and D--r = .61, iPTH and 25OHD--r = -.43, iPTH and serum phosphorous--r = .59.

CONCLUSIONS

The more adequate the state of vitamin D nutriture, the lower the serum iPTH in perimenopausal women and elderly men and the less bone loss in elderly women. The Ca:P ratio in the diet may be important in maintaining bone density in perimenopausal women.

Endocrine studies in a male patient with choriocarcinoma and gynecomastia

Sex hormone profiles were studied in serum and tumor extracts of a man with pulmonary choriocarcinoma and gynecomastia. Although levels of serum estrogens were elevated as expected, serum androgen levels were uncharacteristically quite high. Tumor extract contained increased quantities of both androgens and estrogens when compared with surrounding normal lung tissue, but lacked the enzymes necessary for androgen biosynthesis while retaining aromatase activity. It is concluded that unlike the usual male patient with choriocarcinoma, the tumor-derived beta-human chorionic gonadotropin stimulated testicular androgen production. These androgens were in turn concentrated by the tumor and converted in part to estrogens. Furthermore, gynecomastia can occur even in the face of high serum androgen concentrations provided total estrogen levels are also disproportionately elevated.

Serum osteocalcin is increased in patients with hyperthyroidism and decreased in patients receiving glucocorticoids

Osteocalcin (OC) is a vitamin K-dependent protein which is synthesized by osteoblasts and is present in the circulation. We measured serum OC concentrations in 10 patients receiving corticosteroids (CS) for chronic obstructive pulmonary disease and in 9 hyperthyroid (HT) patients. Mean values ( +/- SE) were as follows: There was a significant correlation between OC and alkaline phosphatase (r = 0.607; P = 0.006) when CS and HT groups were combined. Elevated serum OC concentrations in hyperthyroid patients may reflect increased osteoblastic activity, while decreased levels in corticosteroid-treated patients may reflect decreased osteoblastic activity.

Androblastomas and thyroid disease in postmenopausal sisters

Androblastomas are virilizing ovarian tumors found predominantly in premenopausal women. Reported are two postmenopausal sisters with androblastomas, the first such occurrence in the literature. An association has been proposed between the familial occurrence of these tumors and thyroid adenomas or nontoxic goiter. Of the two patients studied, one had a history of Graves disease and the other had thyroid cancer. The authors conclude that the associated thyroid pathology in the families described and in the studied patients is inconsistent and does not represent a unique multiple endocrine neoplasia syndrome.

Hepatocellular carcinoma: an unusual course with hyperthyroidism and inappropriate thyroid-stimulating hormone production

A 61-yr-old woman was found to have multicentric hepatocellular carcinoma associated with clinical hyperthyroidism. Marked elevations in serum thyroid-stimulating hormone, T4, T3, and free T4 were documented. These values increased with tumor progression. It is postulated that this patient's hepatoma produced a substance stimulating thyroid-stimulating hormone synthesis and secretion with resultant inappropriate thyroid-stimulating hormone production and thyrotoxicosis. This unusual association of hepatocellular carcinoma with clinical and biochemical evidence of hyperthyroidism and inappropriate thyroid-stimulating hormone production has not been previously reported.

Pyomyositis. Increasing recognition in temperate climates

Pyomyositis is common in the tropics yet is rarely reported in temperate climates. A woman in whom pyomyositis developed in a temperate climate is presented. Computed tomography was the key in the diagnosis of the disease involving the muscles of the left lateral chest wall. The patient's condition responded to intravenous antibiotics and open abscess drainage. The 31 cases reported in the United States are reviewed. Unfamiliarity still poses a barrier to early diagnosis, although pyomyositis is being more frequently described in temperate climates.

Osteoporosis--a review and update

Osteoporosis is a common disorder in women. Fifty percent of women more than 65 years of age have bone mineral density below the fracture threshold. Factors which accelerate bone loss include deficiency of gonadal hormones, nutritional effects, lack of exercise, smoking, alcoholism and endocrinopathies. Fractures of the hip, vertebra and radius occur much more frequently in patients with osteoporosis. Chronic pain is caused by compression fractures of vertebrae resulting in mechanical changes in the spine. The most desirable treatment is prevention. Adequate dietary intake of calcium, exercise and avoidance of excess intake of protein and phosphorus should be advised. Treatment with fluoride is promising but requires further study.

Long-term anticonvulsant therapy and intestinal calcium absorption

Twelve patients on anticonvulsant therapy were studied to determine whether or not the drugs induced alterations in gastrointestinal absorption of calcium, response to parathyroid hormone (PTH), or serum 25-hydroxy vitamin D (25-OHD) concentrations. Fractional calcium absorption (FCaA) was determined by giving 45Ca intravenously and orally. The short-term response to PTH was assessed by giving 200 U of parathyroid extract (PTE) intravenously over 15 min and measuring hourly urine cyclic adenosine monophosphate (cAMP) and tubular reabsorption of phosphate (TRP). Calcemic response to PTH was followed by giving intramuscular injections of PTE, 200 U every 6 hr. FCaA was 30.8 +/- 3.7% lower than the normal of 42.2 +/- 2.5% (P less than 0.025), and baseline 25-OHD levels were 30.5 +/- 3.4 ng/ml (normal 15 to 50 ng/ml). Anticonvulsant drugs did not alter renal response to PTE. There was a rise in urinary cAMP from 3.7 +/- 0.23 to 6.1 +/- 0.47 mumol/gm creatinine (P less than 0.005) with a fall in TRP from 87.8 +/- 1.2% to 78.8 +/- 1.6% (P less than 0.005). Serum calcium rose from 9.4 +/- 0.1 to 11.1 +/- 0.3 mg/dl (P less than 0.005). We conclude that FCaA is low in patients receiving anticonvulsant drugs, even when serum 25-OHD levels and the response of bone and kidney to PTH remain normal.

Predicting weight loss success among obese clients in a hospital nutrition clinic

A retrospective study of 63 obese patients seen in a hospital outpatient nutrition clinic was reported. The majority suffered from one or more other medical problems. The relationship of amount of and rate of weight loss to various factors was examined. The multivariate analysis revealed that either the amount or rate of weight loss was greater in the patients who were more overweight initially, white, male, young, single, older at age of onset of obesity, visited the clinic for a longer period of time but less frequently. Conversely, the amount or rate of weight loss was less in those patients receiving conjugated estrogens, oral contraceptives, propranolol, thioridazine HCl, and those who were receiving behavior modification as treatment.

Effects of hydrochlorothiazide and dietary sodium restriction on calcium metabolism in corticosteroid treated patients

The effect of treatment with hydrochlorothiazide (HCT) and dietary sodium restriction on calcium economy in glucocorticoid-treated patients was investigated. Fractional 47Ca intestinal absorption (FCaA) and fractional urinary calcium excretion (FCaEx) were measured in six normal individuals and in ten patients receiving glucocorticoids for chronic obstructive pulmonary disease before and after 60 days of treatment with a 50 mEq sodium diet and HCT 50 mg twice daily. FCaA was significantly decreased on glucocorticoid-treated patients (27.5 +/- 4.3%) when compared to normal individuals (41.8 +/- 2.8%, p less than 0.005). A significant increase in FCaA to 38.9 +/- 4.8%, (P less than .05) was seen in glucocorticoid-treated patients after treatment with HCT and dietary sodium restriction. Baseline FCaEx was higher in glucocorticoid-treated patients than in the normal subjects. A significant decrease in FCaEx after dietary sodium restriction and thiazide administration occurred in both normal (0.99 +/- 0.28% before vs. 0.69 +/- 0.30% after; p less than .025) and glucocorticoid-treated patients (1.46 +/- 0.19% before vs. 0.73 +/- 0.13% after p; less than 0.025). These data suggest that dietary sodium restriction and HCT therapy may improve total body calcium economy in glucocorticoid-treated patients by increasing intestinal calcium absorption and decreasing urinary calcium excretion.

Glucocorticoids increase osteoblast-like bone cell response to 1,25(OH)2D3

Recent reports indicate that some hormones may regulate the binding of, and subsequent response to, other hormones by their target tissue. The adrenal glucocorticoids are prominent among these modulating hormones. Glucocorticoids have been shown to enhance bone cell sensitivity to parathyroid hormone (PTH) in vitro and this in turn has permitted PTH-induced effects to be measured at physiological doses of PTH for the first time in isolated osteoblast-like (OB) and osteoclast-like (OC) cells. It is unknown whether these findings represent a specific interaction between glucocorticoids and PTH or indicate a general role for glucocorticoids in the development and/or maintenance of bone cell differentiation, of which hormonal responsiveness would be one expression. In the event of a general glucocorticoid effect on cell differentiation, increased responsiveness to other bone resorbing hormones should also be observed. We have therefore examined whether glucocorticoids enhance the sensivity of bone cells to a steroid hormone, 1,25 dihydroxycholecalciferol (1,25(OH)2,D3), and we report here that they do.

Resolution of breast pain and calcification with renal transplantation

Vascular calcification in chronic renal failure and dialysis patients is well-documented and generally considered to be a consequence of decreased phosphorus excretion, secondary hyperparathyroidism, and increased calcium-phosphorus product. Following renal transplantation or parathyroidectomy, gradual resolution of metastatic calcification in the affected areas occurs. The case presented documents the consequence of secondary hyperparathyroidism with calcification of mammary vessels leading to severe breast pain with resolution of the pain and vessel calcification after renal transplantation.

Vitamin D metabolism in man. Effect of corticosteroids

This study evaluated the effects of acute intravenous calcium supplementation on vitamin D metabolism in nine patients maintained on long-term prednisone therapy for chronic obstructive lung disease. Vitamin D turnover studies, employing 1,2-(3)H,4(14)C vitamin D3, and coincident measurement of serum 25-hydroxycholecalciferol (25-OHCC) concentrations demonstration (P less than .05) and half-time (P less than .05) in the prednisone-treated patients when compared with the mean 25-OHCC concentration and half-time found in these patients prior to calcium infusion. However, there was no significant difference in the amounts of 24,25-(OH)2CC) or 1,25-dihydroxycholecalciferol (1,25-(OH)2CC) appearing after calcium infusion. The results of the study showed that the intravenous administration of calcium to corticosteroid-treated patients accelerated the disappearance of 25-OHCC from the plasma of these patients without parallel increases in the production of 1,25-(OH)2CC or 24-25-(OH)2CC.

Calcium and phosphorus homeostasis in man. Effect of corticosteroids

Serum calcium and phosphorus levels, urinary excretion rates of calcium, phosphorus, and cyclic adenosine monophosphate (cAMP), and plasma parathyroid hormone (PTH) concentrations were determined in 11 normal subjects and in nine patients maintained on long-term prednisone therapy for chronic obstructive pulmonary disease. These same determinations were repeated in five of the prednisone-treated patients during the course of a seven-day calcium infusion. Prior to the infusion, the prednisone-treated patients demonstrated significantly elevated serum levels of PTH (P less than .005) and increased rates of urinary phosphate and cAMP excreation (P less than .005) when compared with normal subjects. After initiation of calcium infusion, the previous elevations in all of these determinations decreased to near normal levels. These data suggest that the effects of secondary hyperparathyroidism in patients maintained on long-term prednisone therapy may be overcome when calcium is administered intravenously.