Calcitonin versus etidronate for the treatment of postmenopausal osteoporosis: a meta-analysis of published clinical trials

Calcitonin and Bone Physiology: In Vitro, In Vivo, and Clinical Investigations

Calcitonin was discovered as a peptide hormone that was known to reduce the calcium levels in the systemic circulation. This hypocalcemic effect is produced due to multiple reasons such as inhibition of bone resorption or suppression of calcium release from the bone. Thus, calcitonin was said as a primary regulator of the bone resorption process. This is the reason why calcitonin has been used widely in clinics for the treatment of bone disorders such as osteoporosis, hypercalcemia, and Paget's disease. However, presently calcitonin usage is declined due to the development of efficacious formulations of new drugs. Calcitonin gene-related peptides and several other peptides such as intermedin, amylin, and adrenomedullin (ADM) are categorized in calcitonin family. These peptides are known for the structural similarity with calcitonin. Aside from having a similar structure, these peptides have few overlapping biological activities and signal transduction action through related receptors. However, several other activities are also present that are peptide specific. In vitro and in vivo studies documented the posttreatment effects of calcitonin peptides, i.e., positive effect on bone osteoblasts and their formation and negative effect on osteoclasts and their resorption. The recent research studies carried out on genetically modified mice showed the inhibition of osteoclast activity by amylin, while astonishingly calcitonin plays its role by suppressing osteoblast and bone turnover. This article describes the review of the bone, the activity of the calcitonin family of peptides, and the link between them.

The Activity of Peptides of the Calcitonin Family in Bone

Calcitonin was discovered over 50 yr ago as a new hormone that rapidly lowers circulating calcium levels. This effect is caused by the inhibition of calcium efflux from bone, as calcitonin is a potent inhibitor of bone resorption. Calcitonin has been in clinical use for conditions of accelerated bone turnover, including Paget's disease and osteoporosis; although in recent years, with the development of drugs that are more potent inhibitors of bone resorption, its use has declined. A number of peptides that are structurally similar to calcitonin form the calcitonin family, which currently includes calcitonin gene-related peptides (αCGRP and βCGRP), amylin, adrenomedullin, and intermedin. Apart from being structurally similar, the peptides signal through related receptors and have some overlapping biological activities, although other activities are peptide specific. In bone, in vitro studies and administration of the peptides to animals generally found inhibitory effects on osteoclasts and bone resorption and positive effects on osteoblasts and bone formation. Surprisingly, studies in genetically modified mice have demonstrated that the physiological role of calcitonin appears to be the inhibition of osteoblast activity and bone turnover, whereas amylin inhibits osteoclast activity. The review article focuses on the activities of peptides of the calcitonin family in bone and the challenges in understanding the relationship between the pharmacological effects and the physiological roles of these peptides.

Calcitonin receptor gene polymorphisms at codon 447 in patients with osteoporosis and chronic periodontitis in South Indian population - An observational study

Context:

Chronic periodontitis and osteoporosis are multifactorial diseases which share common risk factors. Interactions between genetic and other factors determine the likely hood of osteoporotic fractures and chronic periodontitis. Calcitonin receptor (CTR) gene polymorphism is one of the important factors which contribute to the development of osteoporosis and chronic periodontitis.

Aims:

This study highlights the association of CTR gene polymorphisms at codon 447 in patients with osteoporosis and chronic periodontitis and healthy controls in south Indian population.

Settings and Design:

The study was designed as a case–control retrospective, observational clinical trial which was conducted to assess the role of CTR gene polymorphism in patients with osteoporosis and periodontitis as well as in healthy controls.

Materials and Methods:

A total of 50 subjects were taken into the study comprising of 20 healthy and 30 osteoporotic subjects with chronic periodontitis between the age group of 30–55 years. Within the limitations of our study, only 50 subjects were taken in the study due to the strict sampling method (Patients who were just diagnosed with osteoporosis and periodontitis and hence not taking any medication). 2 ml of blood sample was collected in ethylenediamine tetra acetic acid containing vials, and polymerase chain reaction was run to identify CTR gene polymorphism.

Statistical Analysis Used:

Statistical analysis was done by student t-test. Pertaining to C > T allele pattern there was a significant difference between the test and control group.

Results:

A significant difference was observed between the test and control group in relation to the C > T allele pattern. Patients showing TT genotype distribution had greater periodontal destruction and lower bone-mineral density compared to CT genotype distribution followed by CC genotype distribution indicating TT homozygotes are more prone to the development of osteoporosis with increased risk of fracture and loss of alveolar bone. Males and females showed equal susceptibility to osteoporosis and chronic periodontitis.

Conclusions:

CTR polymorphism at codon 447 may be associated with osteoporosis and chronic periodontitis

Effects of calcitonin on the biomechanics, histopathology, and radiography of callus formation in rats

BACKGROUND

This study was designed to examine the effect of salmon calcitonin on fracture repair.

METHODS

A transverse middiaphyseal fracture of the right tibia was surgically induced, and stabilized by an intramedullary Kirschner wire. Eighty male Wistar rats were arbitrarily assigned to four groups of 20 animals each. Groups I and II were the controls and did not receive any medication but did receive placebo injections. The other two groups received 5 IU/kg/day salmon calcitonin intramuscularly for 6 weeks (Group III) or for 10 weeks (Group IV) postoperatively. The formation and healing of the bones were determined by radiographic and histopathological analyses and by biomechanical tests.

RESULTS

In radiographic examinations, there were no statistically significant differences between groups I and III at week 6 or between groups II and IV at week 10. However, the histopathological evaluation scores were higher in the calcitonin group at the early stage (6 weeks) of fracture healing, which indicates a more mature callus formation (P < 0.05). The values for maximum torsional moment during fracture were higher in the calcitonin group in both stages of fracture healing (P < 0.01).

CONCLUSIONS

This study could have two important clinical implications. (1) Higher scores for the histopathological evaluation and a greater resistance to moment force applied at an early stage (week 6) of fracture healing imply that calcitonin intake might enable us to allow earlier mobilization and weight-bearing in clinical cases with rigid fixation. (2) At a late stage of fracture healing (week 10), the significantly better (P < 0.0001) results obtained in the biomechanical parameters used might imply that calcitonin intake could enable us to perform early implant removal, and strongly suggest that the strength and quality of the callus formation could be improved by administering calcitonin following a fracture.

Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women

BACKGROUND

Osteoporosis is an abnormal reduction in bone mass and bone deterioration leading to increased fracture risk. Etidronate belongs to the bisphosphonate class of drugs which act to inhibit bone resorption by interfering with the activity of osteoclasts.

OBJECTIVES

To assess the efficacy of etidronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE and EMBASE for relevant randomized controlled trials published between 1966 to 2007.

SELECTION CRITERIA

Women receiving at least one year of etidronate for postmenopausal osteoporosis were compared to those receiving placebo and/or concurrent calcium/vitamin D. The outcome was fracture incidence.

DATA COLLECTION AND ANALYSIS

Study selection and data abstraction was done in duplicate. Meta-analysis of fracture outcomes was performed with data presented as relative risks and a relative change greater than 15% was considered clinically important. Study quality was assessed through the reporting of allocation concealment, blinding and withdrawals.

MAIN RESULTS

Eleven studies representing a total of 1248 patients were included in the review.A significant 41% relative risk reduction (RRR) in vertebral fractures across eight studies (RR 0.59, 95% CI 0.36 to 0.96) was found. The six secondary prevention trials demonstrated a significant RRR of 47% in vertebral fractures (RR 0.53, 95% CI 0.32 to 0.87) and a 5% absolute risk reduction (ARR); compared with the pooled result for the two primary prevention trials (RR 3.03, 95% CI 0.32 to 28.44), which was not significant. There were no statistically significant risk reductions for non-vertebral (RR 0.98, 95% CI 0.68 to 1.42), hip (RR 1.20, 95% CI 0.37 to 3.88) or wrist fractures (RR 0.87, 95% CI: 0.32 to 2.36). For adverse events, no statistically significant differences were found in the included studies. However, observational data has led to concerns regarding potential risk for upper gastrointestinal injury.

AUTHORS' CONCLUSIONS

Etidronate, at 400 mg per day, demonstrated a statistically significant and clinically important benefit in the secondary prevention of vertebral fractures. No statistically significant reductions in vertebral fractures were observed when it was used for primary prevention. In addition, no statistically significant reductions in non-vertebral, hip, or wrist fractures were found, regardless of whether etidronate was used for primary or secondary prevention. The level of evidence for all outcomes is Silver (www.cochranemsk.org.).

WITHDRAWN: Etidronate for treating and preventing postmenopausal osteoporosis

BACKGROUND

Osteoporosis is a clinical syndrome of reduced bone mass and increased fracture susceptibility. There are now a number of options, including etidronate which can decrease the risk of fractures.

OBJECTIVES

To systematically review the efficacy of etidronate on bone density, fractures and toxicity in postmenopausal women.

SEARCH STRATEGY

We searched MEDLINE from 1966 to December 1998, examined citations of relevant articles, and the proceedings of international osteoporosis meetings. We contacted osteoporosis investigators to identify additional studies, primary authors, and pharmaceutical industry sources for unpublished data.

SELECTION CRITERIA

We included thirteen trials (with 1010 participants) that randomized women to etidronate or an alternative (placebo or calcium and/or vitamin D) and measured bone density for at least one year.

DATA COLLECTION AND ANALYSIS

For each trial, three independent reviewers assessed the methodological quality and abstracted data.

MAIN RESULTS

The data suggested a reduction in vertebral fractures with a pooled relative risk of 0.60% (95% CI 0.41 to 0.88). There was no effect on non-vertebral fractures (pooled relative risk 1.00, (95% CI 0.68 to 1.42)). Etidronate, relative to control, increased bone density after three years of treatment in the lumbar spine by 4.27% (95% CI 2.66 to 5.88), in the femoral neck by 2.19% (95% CI 0.43, 3.95) and in the total body by 0.97% (95% CI 0.39, 1.55). Effects were larger at 4 years, though the number of patients followed was much smaller.

AUTHORS' CONCLUSIONS

Etidronate increases bone density in the lumbar spine and femoral neck. The pooled estimates of fracture reduction with etidronate are consistent with a reduction in vertebral fractures, but no effect on non-vertebral fractures.

Osteoporotic compression fractures of the spine; current options and considerations for treatment

BACKGROUND CONTEXT

Vertebral compression fractures affect at least one-fourth of all postmenopausal women. The most significant risk factor is osteoporosis, most commonly seen among Caucasian women a decade or so after menopause. Osteoporosis typically results from inadequate accumulation of bone mass during childhood and early adulthood followed by rapid resorption after menopause. Primary treatment of osteoporosis includes consideration of underlying metabolic abnormalities and provision of supplemental calcium/vitamin D in conjunction with bisphosphonates or calcitonin, or both. Routine hormone replacement therapy has fallen out of favor because of concerns regarding adverse effects identified in long-term follow-up studies. Acute osteoporotic vertebral compression fracture management includes bracing, analgesics, and functional restoration. Patients with chronic pain beyond 2 months may be appropriate candidates for vertebral body augmentation, ie, vertebroplasty or balloon tamp reduction. Open surgical management with decompression and stabilization should be reserved for the rare patient with neural compression and progressive deformity with neurologic deficits.

PURPOSE

To review current principles in the evaluation and treatment of osteoporotic compression fractures of the spine.

STUDY DESIGN/SETTING

A literature review on management of the osteoporotic spine.

METHODS

MEDLINE search of all English-language literature published between 1981 and 2005 on surgical and nonsurgical treatment of the osteoporotic spine. The references selected for listing at the conclusion of this review are those containing specific information cited within the text.

RESULTS

Over 200 separate scientific and clinical studies addressing the epidemiology, pathophysiology, diagnosis, and treatment of osteoporotic vertebral compression fractures were reviewed.

CONCLUSIONS

Osteoporotic vertebral compression fractures are a common presenting complaint to spinal care specialists. Thorough differential diagnosis should be considered before attributing fractures to osteoporosis. Appropriate evaluation and medical treatment of underlying osteoporosis should be recommended or instituted. Nonsurgical management of the spinal fracture should focus on pain control and maximizing functional outcome. The role of surgical treatment remains controversial and should be reserved for patients who fail initial nonsurgical management options.

Tratamiento de la pérdida de masa ósea en la mujer postmenopáusica

In this revision, the results of different controlled clinical trials and metaanalyses on the efficacy in the increase of bone mineral density (BMD) and reduction of risk of fracture on postmenopausal osteoporosis treatments are summarized. Most of the drugs studied produce significant BMD increases but with significant differences regarding fracture risk reduction, especially regarding extravertebral fractures. Bisphosphonates and selective estrogen receptor modulators would constitute the first line of treatment of postmenopausal osteoporosis with previous fractures. Head to head studies would be necessary to know its true efficacy since some results are based on post hoc analysis. Possible side effects, risks, treatment comfort and price in addition to the demonstrated efficacy in fracture prevention must be considered in the selection of treatment.

Osteoporosis in Systemic Lupus Erythematosus Mechanisms

Osteoporosis is a potentially preventable condition frequently encountered in patients who have systemic lupus erythematosus (SLE). Bone loss in SLE is heterogeneous and likely a multifactorial process involving both traditional and lupus-related risk factors. Recognizing potential contributors to bone loss in the SLE patient may allow for earlier detection of osteoporosis and optimize bone health. This article reviews the current epidemiologic information available on osteoporosis and fracture data in SLE and discusses evaluation and management strategies pertinent to patients who have lupus.

Osteoporosis management in the new millennium

The prevalence of osteoporosis in all US postmenopausal women is 17%, and it is as high as 30% in women older than 65. All postmenopausal women should be encouraged to have adequate daily calcium and vitamin D intake, to exercise regularly, and to avoid tobacco and excessive alcohol use. Although the clinical impact and cost-effectiveness of osteoporosis screening tools remain to be established, a rational approach based on current evidence involves using National Osteoporosis Foundation guidelines, Simple Calculated Osteoporosis Risk Estimation, or Osteoporosis Risk Assessment Instrument clinical decision rules to decide when a postmenopausal woman should undergo further evaluation.

Prevention of postmenopausal bone loss with exchange for short-term HRT for 1alpha-hydroxycholecalciferol

OBJECTIVE

The present study investigated bone turnover with exchange of hormone replacement therapy (HRT) by treatment with 1alpha-hydroxycholecalciferol in early postmenopausal women.

METHODS

Subjects included a total of 75 postmenopausal women between 49 and 59 years of age who visited the Department of Obstetrics and Gynecology at Osaka Medical College Hospital for regular gynecological checkups and menopausal disorder, postmenopausal osteoporosis or hyperlipidemia, and were diagnosed with menopausal disorder or osteopenia. Changes in bone turnover and vertebral bone mineral density (BMD) in 28 patients who had undergone HRT; conjugated equine estrogen 0.625 mg daily and medroxyprogesterone acetate 2.5 mg daily) for at least 2 years and then switched to 1alpha-hydroxycholecalciferol (0.5 microg orally twice daily) and in 26 patients who were observed without drug administration after discontinuation of HRT were compared with those in 37 patients who continued HRT. BMD of the lumbar spine (L2-4) was determined using Dual Energy X-ray Absorptiometry.

RESULTS

While we observed a significant decrease in vertebral bone mass in the HRT-no medication group at 12 months (P=0.049) and 18 months (P=0.013), there was no significant decrease in vertebral bone mass in either the continuous HRT group or the group with change of HRT to 1alpha-hydroxycholecalciferol. In the group with change of HRT to 1alpha-hydroxycholecalciferol, although urinary pyridinoline level increased significantly from the baseline level throughout the study period (P<0.05), serum propeptide of type-1 procollagen (P1CP) level also increased significantly from the baseline level throughout this period (P<0.001). Furthermore, significant increase from the baseline value (P<0.01) was observed in serum osteocalcin level at 6, 12 and 18 months.

CONCLUSIONS

These results indicate that switching to 1alpha-hydroxycholecalciferol therapy after short-term HRT increased both bone resorption and bone formation, and permitted maintenance of increase in bone mass due to HRT for at least 18 months, though this switching accelerated bone turnover. This may have occurred because stimulation of bone formation induced by HRT was maintained by 1alpha-hydroxycholecalciferol, though bone turnover was slightly promoted because of withdrawal of HRT. This method was thus found to be very effective in preventing bone loss in patients who have discontinued HRT and are considered relatively contraindicated for use of estrogen.

Current medical, rehabilitation, and surgical management of vertebral compression fractures

Approximately 25% of women over the age of 50 in the United States will suffer one or more vertebral compression fractures (VCFs) related to osteoporosis. VCFs are the most common of all osteoporotic fractures, with an incidence of approximately 700,000 annually. Such a fracture may cause significant pain, disability, and loss of general health and mobility and may lead to a progressive decline in quality of life. This is a review of the clinical literature on VCFs, including patient presentation, methods of diagnosis, and current rehabilitation and medical management. Much of the pain and disability that follow a VCF may be minimized by addressing the psychological impact of such a fracture, using current medications to help limit bone loss and preserve bone mass, adhering to a well-planned rehabilitation program, and consideration of vertebroplasty or kyphoplasty in appropriate patients. A multifaceted approach will help to optimize recovery from a VCF related to osteoporosis.

Meta-analyses of therapies for postmenopausal osteoporosis. VI. Meta-analysis of calcitonin for the treatment of postmenopausal osteoporosis

OBJECTIVE

To review the effect of calcitonin on bone density and fractures in postmenopausal women.

DATA SOURCE

We searched MEDLINE and EMBASE from 1966 to 2000 and examined citations of relevant articles and the proceedings of international osteoporosis meetings. We contacted osteoporosis investigators to identify additional studies and primary authors for unpublished data.

STUDY SELECTION

We included 30 studies that randomized women to calcitonin or an alternative (placebo or calcium and/or vitamin D) and measured bone density or fracture incidence for at least 1 yr.

DATA EXTRACTION

For each trial, three independent reviewers assessed the methodological quality and abstracted data.

DATA SYNTHESIS

Calcitonin reduced the incidence of vertebral fractures, with a pooled relative risk (RR) of 0.46 [95% confidence interval (CI) 0.25-0.87, P = 0.02, n = 1404, 4 trials]. However, the RR from the one relatively large randomized controlled trial (RCT) was 0.79 (95% CI 0.62-1.00, P = 0.05, n = 1108). For nonvertebral fractures, the pooled RR was 0.52 (95% CI 0.22-1.23, P = 0.14, n = 1481, 3 trials). Once again, the single large trial showed a less impressive effect than the smaller trials (RR 0.80, 95% CI 0.59-1.09, P = 0.16, n = 1245). For bone density of the lumbar spine, the pooled weekly dose of 250 to 2800 IU per week resulted in significant increase in the weighted mean difference (WMD) of 3.74 (2.04-5.43, P < 0.01, n = 2260, 24 trials). The combined forearm showed a similar effect, with a WMD of 3.02 (95% CI 0.98-5.07, P < 0.01, n = 468, 9 trials). At the femoral neck, the pooled weighted mean difference showed a nonsignificant trend toward benefit, WMD 3.80 (95% CI -0.32-7.91, P = 0.07, 9 trials, n = 513). Methodologically weaker studies tended to show greater effects on bone density, and the lumbar spine results suggested the possibility of publication bias.

CONCLUSIONS

Calcitonin likely increases bone density in postmenopausal women predominantly at the lumbar spine and forearm for weekly doses of greater than 250 IU, although the true effect may be smaller than the pooled estimate would suggest. Calcitonin likely reduces the risk of vertebral fracture; its effect on nonvertebral fracture remains uncertain.

Maximizing health in menopausal women with disabilities

There are nearly 30 million women with disabilities in the United States. Of these, more than 16 million are over the age of 50. Years ago, women with disabilities did not commonly live to the age of menopause, and, if they did, they reached this stage of life in a very debilitated condition. Now, women with disabilities are entering their mature years as active members of society who can look forward to productive futures. Because the health needs of women with disabilities might differ from those of other women, special attention should be focused on how physiological changes of perimenopausal and menopausal states affect this population. In addition to functional changes that might affect menopausal women with disabilities, basic health maintenance issues may be adversely affected by environmental factors. Physical barriers can influence compliance with preventive health screening that is essential in aging populations. Treatment options might need to be tailored to the individual. The disabling condition itself may progress, resulting in secondary conditions requiring creative interventions. A comprehensive evaluation and the development of a suitable management plan, which takes into account the multifactorial nature of aging as a disabled woman, are essential in delivering optimal care to this population.

Effects of the combined use of calcitonin and 1 alpha-hydroxycholecalciferol on vertebral bone loss and bone turnover in women with postmenopausal osteopenia and osteoporosis: a prospective study of long-term and continuous administration with low dose calcitonin

OBJECTIVES

The present study investigates the effect of long-term and continuous treatment with low dose calcitonin in combination with 1 alpha-hydroxycholecalciferol on vertebral bone mass in early postmenopausal women.

METHODS

A total of 202 postmenopausal women between 53 and 58 years of age were recruited individually and randomly assigned to one of four groups. Comparisons were made among groups of women receiving calcitonin alone (10 IU i.m. twice a month), 1 alpha-hydroxycholecalciferol alone (0.5 microg orally twice daily), a combination of the above two agents, or no treatment. Bone mineral density (BMD) of lumber spine (L2-4) was determined using Dual Energy X-ray Absorptiometry. The study was carried out prospectively over a 2-year period.

RESULTS

We observed a significant increase in vertebral bone mass in the combined treatment regimen of calcitonin and 1 alpha-hydroxycholecalciferol (3.44% at 12 months in the combination group vs 1.40,0.92, and -0.70% in the calcitonin alone, 1 alpha-hydroxycholecalciferol alone, and control groups, respectively; 4.51% at 24 months in the combination group vs 2.21,1.04, and -3.61% in the calcitonin alone, 1 alpha-hydroxycholecalciferol alone, and control groups, respectively). Serum PTH, osteocalcin levels and alkaline phosphatase activity decreased significantly within 12 months whereas urinary pyridinoline/creatinine ratio decreased at 24 months in the combination group. We observed mild adverse effects in 25.0% (7/28) and 30.0% (6/20) of combination regimen and calcitonin treatment cases, respectively.

CONCLUSIONS

The results of the study suggest that the combination treatment regimen increased vertebral bone loss in early postmenopausal women to a greater extent than did calcitonin alone or 1 alpha-hydroxycholecalciferol alone.

Role of bisphosphonates and calcitonin in the prevention and treatment of osteoporosis

Bisphosphonates have been shown to increase bone mineral density in patients with established osteoporosis as well as those with osteopenia. The evidence conclusively shows a reduction in fracture rates in patients on the more potent nitrogen containing bisphosphonates. Indeed, significant vertebral fracture rate reduction has been demonstrated after only 1 year of therapy. Alendronate, a second-generation bisphosphonate, and risedronate, a third-generation bisphosphonate, are first line medications for the treatment of osteoporosis given their efficacy in preventing both vertebral and non-vertebral fractures. There is evidence that vertebral fractures may be prevented by intermittent cyclic therapy with etidronate. All three have been shown to increase bone mineral density in the spine, with alendronate and risedronate producing significant increases in hip bone density. Calcitonin has demonstrated the ability to reduce vertebral fracture rates with minimal changes in bone density. Calcitonin is also beneficial in reducing the bone pain associated with fractures.

Expert physician recommendations and current practice patterns for evaluating and treating men with osteoporotic hip fracture

OBJECTIVES

To develop recommendations for the evaluation and the treatment of men with osteoporotic hip fracture from expert publications in the field of male osteoporosis, and to define the current practice patterns in a tertiary care VA Medical Center in Durham, North Carolina.

DESIGN

Survey research; a retrospective cohort study.

SETTING

Tertiary care VA Medical Center in Durham, North Carolina.

PARTICIPANTS

(1) US physicians who published on the subject of male osteoporosis in the peer-reviewed literature between 1993 and 1997 identified by MEDLINE database search. (2) All 119 men admitted to the Durham VA Medical Center with ICD9 code for hip fracture between 1994 and 1998.

OUTCOME MEASURES

(1) Osteoporosis evaluation and treatment recommendations of published physicians obtained by survey instrument. (2) Actual osteoporosis evaluation completed and therapy prescribed during index hospitalization in a cohort of men with hip fractures, determined by chart and database review.

RESULTS

(1) Forty-three physician-researchers were surveyed with an 84% response rate. For an osteoporosis evaluation, 89% of respondents recommended measuring serum testosterone, 85% serum calcium, 75% 25-OH vitamin D levels, 73% myeloma screen, and 61% serum thyroid-stimulating hormone (TSH). Dual Energy X-ray Absorptiometry would be obtained by 92%. More than 70% recommended calcium, vitamin D, and bisphosphonates for men with a normal metabolic evaluation, and 60% suggested weight-bearing exercise. (2) In the cohort of men admitted with hip fractures, 50% had a serum calcium level and 3% had a serum TSH level measured. Vitamin D was prescribed to 25% of patients in the form of a multivitamin, and 4% received calcium. There was no bisphosphonate, testosterone, or calcitonin use.

CONCLUSIONS

Physicians who have published on osteoporosis recommended metabolic evaluation and osteoporosis therapy after hip fracture. Only minimal evaluation and treatment occurred in a cohort of men with osteoporotic hip fractures.

Preventing fractures in postmenopausal women with osteoporosis. A review of recent controlled trials of antiresorptive agents

The evidence from randomised, controlled trials of the ability of antiresorptive treatments to reduce the risk of fractures in postmenopausal women with osteoporosis is reviewed and summarised. The aminobisphosphonates, alendronic acid and risedronic acid, and the selective estrogen receptor modulator raloxifene have all been shown to reduce the incidence of radiographic vertebral fractures. Only alendronic acid and risedronic acid have been shown to reduce the incidence of non-spine fractures in women with postmenopausal osteoporosis. There is evidence of antifracture efficacy for calcium plus vitamin D, primarily in a nursing home setting or in people with low intakes of these nutrients. Furthermore, since both the placebo and active treatment groups received calcium and vitamin D in most controlled trials of antiresorptive agents, it appears that the other agents provide benefits beyond those of calcium and vitamin D alone. There is insufficient published evidence from randomised controlled trials to convincingly support the antifracture efficacy of other agents, including calcitonin, estrogen and etidronic acid, at this time. Data from observational studies suggest, however, that estrogen and etidronic acid may have antifracture efficacy in this population.

Osteoporosis

Osteoporosis is a disorder of decreased bone mass, microarchitectural deterioration, and fragility fractures. Osteoporosis is widespread and can affect people of all ethnic backgrounds and many older women and men. An essential element in preventing osteoporosis is the achievement of normal peak bone mass. Adequate nutrition, appropriate calcium and vitamin D intake, regular menstrual cycles and a well balanced exercise program of exercise are essential elements in achieving peak bone mass. At menopause women undergo accelerated bone loss. Thereafter, women and men gradually lose bone mass. A loss of one standard deviation give rise to an enhanced twofold risk of spine fractures or a 2.5 risk of hip fracture. Bone mass is determined by dual energy x-ray absorptiometry, quantitative computed tomography scan, and a peripheral ultrasound. Dual energy x-ray absorptiometry has outstanding precision (within 1% to 2%), and has the ability to show the efficacy of drug intervention. Peripheral measurements may identify osteoporosis but only have a 70% correlation with hip and spine bone mass. Dual energy x-ray absorptiometry determines bone mass in a patient but the bone collagen breakdown products (N-telopeptide crosslinks) establish the current rate of bone loss. Major risk factors leading to fragility fracture include low body weight, history of fracture, family history of osteoporosis, and smoking. All individuals should ingest adequate calcium and vitamin D, exercise, and prevent falls. Women with low bone mass, high urinary bone collagen breakdown products, and/or major risk factors should consider hormone replacement therapy or a selective estrogen receptor modulator (Evista), calcitonin and bisphosphonates (alendronate). These agents successfully increase bone mass and limit fracture risk. Men at risk for fragility fractures respond similarly as women to alendronate and calcitonin. Although vertebral compression fractures can occur spontaneously, hip fractures are attributable to low bone mass coupled with a fall. Hence, fall prevention programs in addition to medical treatment are critical in the prevention of fragility fractures.

Effect of calcitonin on bone and connective tissue metabolism in hemiplegic patients: a two-year prospective study

OBJECTIVES

To test the effects of 200 IU/day of a nasal spray of salmon calcitonin in modulating the increased bone tissue metabolism observed in hemiplegic patients.

DESIGN

A two-year, prospective, randomized, double-blind, placebo-controlled study.

PATIENTS

Thirty-four patients with hemiplegia due to a cerebrovascular accident were included in the study during the first month after onset of hemiplegia after giving their informed consent. All patients followed a suitably planned course of active rehabilitation according to Bobath. They were randomly allocated to either the calcitonin or the placebo group but all of them received a daily oral calcium supplementation of 1000 mg.

RESULTS

Biochemical markers of bone formation, serum total alkaline phosphatase, osteocalcin and type I procollagen did not vary during the two years of follow-up. Cross-linked carboxy-terminal telopeptide of type I collagen, a biochemical marker of bone resorption, was elevated initially after stroke and then decreased significantly (p <0.001), stabilizing as of month 12. Urinary calcium/creatinine and total hydroxyproline/creatinine ratios presented with similar profiles. The serum levels of the type III procollagen, a marker of connective tissue metabolism, were also elevated upon entry and decreased thereafter. No significant difference could be found between the calcitonin-treated and the placebo group for any of the biochemical markers at any time point.

CONCLUSION

This prospective study demonstrated that biochemical markers of bone and connective tissue metabolism were elevated shortly after the occurrence of stroke and then gradually decreased during the first two years after injury. The daily administration of 200 IU of intranasal calcitonin did not influence the levels of these markers.

Osteoporosis: intervention options

Osteoporosis is a systemic progressive disease with important clinical complications because of the fractures that arise and cause major morbidity in especially the aging postmenopausal women. Because of the relative not complex procedure of diagnosis and prediction the most important question to answer: is treatment possible? There are now a variety of treatments available for the management of osteoporosis. The inhibitors of bone resorption, which include calcium, the vitamin Ds, bisphosphonates, calcitonins and gonadal steroids have been variously shown to prevent bone loss or to reduce fractures. On the other hand bone formation stimulating agents as fluorides and in the near future parathyroid hormone and analogues must be considered also. However, randomized clinical trials with fractures as clinical endpoints are only few in number and not present for every suggested treatment. During the last 3 years it has become clear that besides estrogen, bisphosphonates and now perhaps the selective estrogen receptor modulators also show a good alternative as intervention option of postmenopausal osteoporosis. At this moment sodium fluoride is not the first choice in treatment of osteoporosis in general practice.