Analysis of 1-year vertebral fracture risk reduction data in treatments for osteoporosis

The Sensitivity of Orthopaedic Surgeons to the Secondary Prevention of Fragility Fractures

BACKGROUND

Orthopaedic surgeons must play an important role in the secondary prevention of fragility fractures; however, some surgeons are more aware than others of their responsibility regarding fracture prevention. The purpose of the present study was to identify which factors can lead to a higher sensitivity for fracture prevention.

METHODS

A cross-sectional survey was distributed to orthopaedic surgeons via online invitation or at academic conferences in China from July through October 2015. A total of 452 surgeons responded. As the primary outcome measure, we created a sensitivity scoring system for fracture prevention based on the respondents' answers to 5 questions regarding behavior in the following areas: risk-factor evaluation, pharmacologic therapy, nonpharmacologic therapy, patient education, and follow-up. Multivariable linear regression and multivariable logistic regression analyses were used to identify factors related to surgeon sensitivity to fracture prevention.

RESULTS

Very few surgeons reported having received adequate training regarding fracture prevention or reading guidelines or other fracture prevention literature (22% and 30%, respectively). Most respondents initiated pharmacologic or nonpharmacologic therapy (82% and 75%, respectively) for the treatment of confirmed osteoporosis among patients with fragility fractures, but only half performed a risk-factor evaluation, patient education, or timely patient follow-up (51%, 52%, and 48%, respectively). In the multivariable linear regression model, the orthopaedic surgeon's age (β = 0.09, p = 0.003), self-rated knowledge level regarding osteoporosis or related issues (β = 0.16, p < 0.001), self-perceived effectiveness in using preventive measures for patients with a fragility fracture (β = 0.62, p < 0.001), and use of clinical pathways for fragility fractures in his or her workplace (β = 1.24, p < 0.001) were independently associated with sensitivity scores for fracture prevention. Similar results were obtained from a multivariable logistic regression model.

CONCLUSIONS

In China, the sensitivity of orthopaedic surgeons to the secondary prevention of fragility fractures is relatively low. Implementation of a comprehensive prevention approach and targeted continuing medical education are required to encourage surgeons to take greater responsibility for screening, treating, educating, and following their patients with fragility fractures.

Osteoporotic Fracture Program management: who should be in charge? A comparative survey of knowledge in orthopaedic surgeons and internists

BACKGROUND

Osteoporosis has been described as a progressive skeletal disorder until a patient experiences a fragility fracture. The number of patients with osteoporotic fractures is increasing at an exponential rate. Orthopaedic surgeons, most of the time, first clinicians seen by patients at the time of fracture, do not routinely consider osteoporosis management. Therefore, we compared the knowledge of orthopaedic surgeons and internists regarding medical treatment required: which group would have more abilities to keep patients with osteoporotic fractures under management?

HYPOTHESIS

We hypothesize that internists may have more abilities to assess and treat osteoporosis for patients with osteoporotic fractures; therefore, referring these patients to this specialized team for post-fracture medical consultation is required.

METHODS

A questionnaire composed of seven closed questions was administered to 4700 orthopaedic surgeons and internists. This question list addressed the orthopaedic surgeons' and internists' knowledge in managing patients with osteoporotic fractures. The questions were designed in a way to cover the topics of diagnosis, treatment, and approach to an osteoporotic patient with osteoporotic fractures.

RESULTS

In this survey, 3431 respondents were included. Only 118 (fewer than 10%) orthopaedic surgeons would order bone mineral densitometry (BMD) in osteoporotic fractures in contrast to 1544 (79%) internists. Approximately 1485 (76%) internists against 487 (33%) orthopaedic surgeons prescribe proper dosage of calcium and vitamin D.

CONCLUSION

Typical orthopaedic surgeon is not naturally inclined to manage patients with osteoporotic fractures. The existing management gap between the occurrence of an osteoporotic fracture and the identification and treatment of osteoporosis requires multifaceted intervention. Improved communication between orthopaedic surgeons and internists may reduce this gap between fracture occurrence and osteoporosis management.

LEVEL OF EVIDENCE

Level III prospective diagnostic study.

High-resolution peripheral quantitative computed tomography for the assessment of bone strength and structure: a review by the Canadian Bone Strength Working Group

Bone structure is an integral determinant of bone strength. The availability of high resolution peripheral quantitative computed tomography (HR-pQCT) has made it possible to measure three-dimensional bone microarchitecture and volumetric bone mineral density in vivo, with accuracy previously unachievable and with relatively low-dose radiation. Recent studies using this novel imaging tool have increased our understanding of age-related changes and sex differences in bone microarchitecture, as well as the effect of different pharmacological therapies. One advantage of this novel tool is the use of finite element analysis modelling to non-invasively estimate bone strength and predict fractures using reconstructed three-dimensional images. In this paper, we describe the strengths and limitations of HR-pQCT and review the clinical studies using this tool.

Effect of chronic glucocorticoid therapy and the gender difference on bone mineral density in liver transplant patients

BACKGROUND

Chronic glucocorticoid therapy (CGT) has been shown to result in bone density loss causing osteoporosis. Patients undergoing liver transplantation (LT) are on CGT and are at increased risk for bone disease. To further study the relationship between CGT and bone loss, we analyzed the bone mineral density (BMD) in relation to the cumulative dose of CGT in patients who had undergone LT.

MATERIALS AND METHODS

We retrospectively collected information on 57 patients who underwent LT more than 1 year ago, which included demographics, cumulative CGT dose, BMD and t-scores of the femur/lumbar vertebra as measured by dual-energy X-ray absorptiometry (DEXA) for 1 and 2 years post-transplant. Patients receiving CGT >3500 mg/1st year were compared with CGT <3500 mg the first year. The group consisted of 75% males and 25% females.

RESULTS

Data showed that all patients on CGT had a moderately increased risk of fracture one year post-transplant. In the high dose group, females had significantly worse femur BMD and t-scores that persisted through the second year. This difference was not seen in the low dose group.

CONCLUSION

We found that all liver transplant patients on CGT have an increased risk of bone disease and that female patients receiving CGT >3500 mg the first year have a much higher risk of bone disease than males and that this risk persists during the second year. Because most of the steroids are given during the 1st month post-transplant, the amount of steroids given in this time period dictates the patients' risk for the subsequent 2 years.

Recommendations for an update of the current (2001) regulatory requirements for registration of drugs to be used in the treatment of osteoporosis in postmenopausal women and in men

Recent advances in the understanding of the epidemiology of osteoporosis suggest that certain parts of the current European guidelines for the registration of drugs in osteoporosis might be no longer substantiated. The object of this review is to provide the European regulatory authorities with an evidence-based working document providing suggestions for the revision of the "Note for guidance for the approval of drugs to be used in postmenopausal osteoporosis" (CPMP/EWP/552/95). Following an extensive review of the literature (1990-2004), the Group for the Respect of Ethics and Excellence in Science (GREES) organized a workshop including European regulators, academic scientists and representatives of the pharmaceutical industry. The outcomes of this meeting reflect the personal views of those who attended and should not, in any case, be seen as an official position paper of any regulatory agency. The group identified a certain number of points that deserve discussion. They mainly relate to the nature of the indication being granted to new chemical entities (treatment of osteoporosis in women at high risk of fracture instead of prevention and treatment of osteoporosis), the requirements of showing an anti-fracture efficacy on all or on major nonvertebral fractures (instead of the hip), the duration of pivotal trials (2 years instead of 3) and the possibility of considering bridging studies for new routes of administration, new doses or new regimens of previously approved drugs. The group also recommends that an indication could be granted for the treatment of osteoporosis in males on the basis of a placebo-controlled study, with bone mineral density changes after 1 year as the primary endpoint, for medications approved in the treatment of osteoporosis in women at high risk of fractures.

Osteoporosis Self-management:Choices For Better Bone Health

Despite recent pharmacologic advances in the prevention and treatment of osteoporosis, the disease remains incurable. Effective disease management ultimately lies in the hands of the individual patient, who must take responsibility for key health behaviors related to bone health. One behavior modification strategy that has proven effective, but which has not previously been applied to osteoporosis, is "self-management." This article describes the principals, evolution, and initial outcomes of a new self-management program, Choices For Better Bone Health. Choices is a group education course directed to postmenopausal women who are at risk or already affected by osteoporosis, and has shown positive results in early evaluations.

Efficacy and safety of long-term bisphosphonates in postmenopausal osteoporosis

Bisphosphonates have been in clinical use since the first approval of etidronate for myositis ossficans progressiva. They have now been used since the early 1990s for osteoporosis. As patients are continued on bisphosphonates and with consideration for bisphosphonate application in younger postmenopausal women, questions of 'how long to treat' are emerging in the clinical community. What is the evidence for continual efficacy and safety? The longest efficacy data where a placebo group was maintained is the 5-year risedronate vertebral fracture data, which demonstrated additional fracture reduction benefit with this bisphosphonate during years 4-5 of use. As bone mineral density (BMD) or biochemical markers of bone resorption (BCM) change very little for at least 1-2 years (and possibly longer) after discontinuing long-term (3-5 years) bisphosphonate use, it seems reasonable to suggest discontinuation for some indefinite period of time after 5 years of use in younger lower-risk postmenopausal women. Monitoring of both BMD and BCM may indicate when to consider reinitiation of bisphosphonate therapy. In higher-risk elderly postmenopausal women who are doing well on long-term bisphosphonate therapy as defined by a stable BMD, height and no incident fractures, the same discussion of a 'honeymoon' period of no treatment could be entertained. However, because there are no data on fracture events post-treatment even without changing BMD or BCM, this author is reluctant to stop bisphosphonates in elderly high-risk patients. My opinion on the continuation of the use in high-risk patients is also predicated on the observations that there does not appear to be any clinically important safety issues with long-term (10-year) use. Concerns about 'oversuppression' of bone turnover and accumulation of microdamage are theoretical and, so far, have no clinical basis for discontinuation in high-risk patients. It will be important, however, for the continual surveillance of bone safety issues by capturing postmarketing fracture data in patients on long-term therapy as well as long-term bone histomorphometry and measurements of bone quality to reassure clinicans about long-term bisphosphonate continuation.

Clinical Use of Teriparatide in the Real World: Initial Insights

OBJECTIVE

To summarize expert opinion regarding clinical application of the recently introduced anabolic agent teriparatide [human parathyroid hormone (1-34)] in treatment of postmenopausal osteoporosis in women, and osteoporosis in men.

SUMMARY

The anabolic agent teriparatide was approved for clinical use by the Food and Drug Administration (FDA) on November 26, 2002. Since the launch of teriparatide, many more questions about clinical use of this exciting agent have emerged than there are answers provided by clinical trials or FDA-approved product labeling. A group of physicians with a broad range of experience in research and clinical applications of teriparatide met recently to address practical issues related to its use. This manuscript is a compendium of the consensus opinions of the authors that attempts to provide practical answers to many real-world questions being asked about teriparatide therapy since its approval by the FDA.