The Importance of Parathyroid Hormone and Vitamin D Status in the Treatment of Osteoporosis and Renal Insufficiency

Serum lipid profiles and their relationship to cardiovascular disease in the elderly: the PREV-ICTUS study

OBJECTIVE

To assess the relationship between different serum lipid profiles and the prevalence of established cardiovascular disease (CVD) in an elderly population.

RESEARCH DESIGN AND METHODS

An analysis was undertaken of the PREV-ICTUS population-based study on Spanish subjects aged > or =60 years. The following definitions were used: abnormal LDL cholesterol (LDL-C): > or =130 mg/dl (> or =3.3 mmol/L), or > or =100 mg/dl (> or =2.5 mmol/L) in those with diabetes or CVD, or treatment with any hypolipidaemic drug; low HDL cholesterol (HDL-C): <40 mg/dl (<1 mmol/L) (men), or <50 mg/dl (<1.3 mmol/L) (women), and abnormal triglycerides (TG): > or =150 mg/dl (> or =1.7 mmol/L) or treatment with fibrates. We defined eight groups: A (normal lipid profile), B (isolated abnormal LDL-C), C (isolated abnormal TG), D (isolated low HDL-C), E (abnormal LDL-C and HDL-C), F (abnormal LDL-C and TG), G (abnormal TG and HDL-C), H (abnormal LDL-C, HDL-C and TG). A multivariate analysis was performed to assess the relationship between each lipid profile and CVD.

RESULTS

A total of 6010 subjects (mean age 71.7 years, 53.5% women, 73.2% with hypertension, 29.2% with diabetes mellitus, 24.3% with CVD), were included in the analysis. LDL-C elevation was present in 78.1%, 23.3% had low HDL-C and 35.7% abnormal TG. Combined dyslipidaemias were frequent (40.3%). Odds ratios (95% confidence intervals) for CVD, compared with those with a normal lipid profile, were 2.07 (1.24-3.46) for abnormal HDL-C (p = 0.005), 4.09 (3.10-5.39) for abnormal LDL-C; 6.41 (4.59-8.95) for abnormal LDL-C plus HDL-C, 5.33 (3.98-7.14) for abnormal LDL-C plus TG and 7.59 (5.51-10.5) for those with the three parameters altered (all p < 0.001). Compared with those with isolated LDL-C elevation, those with abnormal LDL-C plus HDL-C had 1.57 (1.30-1.97) higher odds of having CVD (p < 0.001), the figures being 1.30 (1.11-1.53) for those with abnormal LDL-C plus TG and 1.86 (1.52-2.28) for those with abnormal LDL-C, TG plus HDL-C (p < 0.001).

CONCLUSIONS

Lipid abnormalities are frequent in the elderly, and are associated with the presence of CVD. Low HDL-C and/or abnormal TG levels, when added to abnormal LDL-C, are associated with a higher prevalence of CVD, suggesting the advisability of a comprehensive lipid evaluation and treatment earlier in life.

Cost-effectiveness of a fixed dose combination of alendronate and cholecalciferol in the treatment and prevention of osteoporosis in the United Kingdom and The Netherlands

OBJECTIVE

To evaluate the cost-effectiveness of a fixed dose combination of alendronate 70 mg and cholecalciferol 2800 IU (alendronate/vitamin D3; Fosavance) versus no treatment, alendronate with dietary vitamin D supplements and ibandronate in the treatment of osteoporosis in the UK and Netherlands.

METHODS

A patient simulation model was developed. One-year cycles included health states related to hip, vertebral, wrist and proximal humerus fractures, as well as death due to hip fractures and other causes. Effect of treatment was extracted from alendronate and ibandronate clinical trials. Direct costs and utilities were derived from other literature. Analyses were performed for women with a history of vertebral fractures and osteoporosis aged 50, 60, 70 and 80 years. Probabilistic sensitivity analyses were undertaken to estimate the uncertainty of outcomes.

RESULTS

In the UK, alendronate/vitamin D3 was cost-effective compared to no treatment in women 70 years and older with osteoporosis ( pound17 439 per quality-adjusted life year [QALY] gained) and women 60 years and older with a history of vertebral fractures ( pound29 283 per QALY gained). For women 80 years of age alendronate/vitamin D3 was cost-saving combined with QALY gains. Alendronate/vitamin D3 was cost-saving relative to alendronate with dietary supplements. Relative to ibandronate, alendronate/vitamin D3 was cost-effective in women 50 years ( pound19 095 per QALY gained) and economically dominant in women 60 years or older. Comparable results were observed for the Netherlands.

CONCLUSIONS

Given the underlying assumptions and data used, this economic modelling study showed that alendronate/vitamin D3 is cost-effective in women 70 years or older with osteoporosis and in women 60 years or older with a history of vertebral fractures in the UK and Netherlands. Alendronate/vitamin D3 is economically dominant over ibandronate in women with a history of vertebral fractures aged 60 and over and cost-saving relative to alendronate with dietary supplements.

Evidence rocks in long-term care, but does it roll?

This article reviews the problems with the implementation of evidence-based care in long-term care. It highlights the fact that many common practices are incompatible with evidence and that available evidence, including evidence about inadvisable and ineffective treatments, is often not followed. Often, there is a tendency to follow recommendations for younger persons (for example, the management of hypertension and elevated cholesterol), or to use questionable interventions (for example, choices for treating constipation). In many cases, the treatments used have only marginal efficacy and increased potential for side effects. This article makes recommendations for improving the approach to evidence-based care in long-term care and strongly urges the FDA to require drug studies in nursing homes.