Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice Guideline

Characteristics of femur morphology and proximal femur bone mineral density in Japanese females with bisphosphonate-related atypical femur fractures

OBJECTIVE

To determine which parameters, including femur morphology, proximal femur bone mineral density, or patient characteristics, are associated with bisphosphonate-related atypical femur fractures (AFFs) and to investigate the relationships between AFF location and these parameters.

MATERIALS AND METHODS

Sixteen females with a history of bisphosphonate use who presented with AFFs and 38 females without AFFs, even those with long-term bisphosphonate use of > 5 years, were compared. Patient characteristics; physique, gait ability, and history of pain and medication, were recorded. In terms of femur morphology, the mechanical lateral distal femoral articular angle (mLDFA), femoral bowing angle, femoral neck - shaft angle, and ratio of the femoral lateral cortex:neck width were measured via anteroposterior femur radiographs. Bone mineral density values of the femur neck, trochanter, inter, and Ward's triangle were used. Logistic regression analysis was conducted to determine independent factors for the AFF. In the 16 AFF patients, AFF locations were divided into 1: subtrochanteric, 2: proximal, 3: middle, and 4: distal femur diaphysis. The Spearman correlation coefficients (rs) between the AFF locations and the parameters were calculated.

RESULTS

Logistic regression analysis revealed that the mLDFA and Ward's triangle values were significantly independently associated with AFF patients (odds ratios = 1.4 and 0.0, respectively). A more distal AFF location was significantly correlated with a shorter body height and greater BMI (rs = -0.69 and 0.67, respectively).

CONCLUSION

An evaluation combining the mLDFA and Ward's triangle value could be used to predict the risk of bisphosphonate-related AFFs. Body height or BMI may be helpful for predicting AFF location.

Pharmacologically targeting fatty acid synthase-mediated de novo lipogenesis alleviates osteolytic bone loss by directly inhibiting osteoclastogenesis through suppression of STAT3 palmitoylation and ROS signaling

Aberrant increases in osteoclast formation and/or activity are the underlying cause of bone loss in a variety of osteolytic diseases. Fatty acid synthase (Fasn)-mediated de novo lipogenesis (DNL) is one of the major lipid metabolic pathways and has been shown to play critical roles in diverse physiological and pathological processes. However, little is known about its role in osteoclastogenesis. Here, we investigate the direct role of DNL in osteoclastogenesis and its therapeutic potential in osteolytic diseases. We found that Fasn expression and DNL levels are upregulated during receptor activator of nuclear factor-κB ligand (RANKL)-induced osteoclastogenesis. Inhibition of Fasn by shRNA knockdown or its pharmacological inhibitors (ASC40 and trans-C75) impairs osteoclast differentiation in vitro. Mechanistically, pharmacological inhibition of Fasn suppresses RANKL-induced c-Fos/NFATc1 expression and thus osteoclastogenesis partly by disrupting STAT3 palmitoylation, while promoting ROS scavenging to impair mitogen-activated protein kinase (MAPK) signaling. Finally, the therapeutic potential of ASC40 for the treatment of osteolytic bone loss is tested in two mouse models of osteolytic diseases, i.e. ovariectomy (OVX)-induced osteoporosis and titanium nanoparticle-induced calvarial osteolysis. The results show that ASC40 significantly attenuates bone loss and osteoclastogenesis in both models. In conclusion, our results demonstrate that Fasn-mediated DNL is a novel positive regulator of osteoclastogenesis and may serve as a promising therapeutic target for the treatment of osteoclast-driven osteolytic bone diseases.

A rare combination of hypogonadotropic hypogonadism, GH deficiency and rectal atresia in a female with an FGFR1 variant: a case report and systematic review of the literature

PURPOSE

To report a case with combined pituitary hormone deficiency (CPHD) and Fibroblast growth factor receptor 1 (FGFR1) gene defect, and summarize the clinical characteristics of similar cases by reviewing the current reports from the literature.

METHODS

A 24-year-old woman was admitted to the outpatient endocrinology unit with a diagnosis of primary amenorrhea, history of Growth Hormone deficiency and multiple congenital anomalies including rectal atresia. The subsequent hormonal investigation led to the diagnosis of hypogonadotropic hypogonadism and persistent GH deficiency. Abdominal and pelvic ultrasounds were normal whereas the brain MRI revealed a hypoplastic sella turcica with a hypoplastic anterior pituitary lobe, an ectopic posterior pituitary lobe and a thin pituitary stalk. The genetic analysis revealed a novel pathogenic missense heterozygous variant (c.1958G > A, p.Agr635Gln) in exon 15 of FGFR1 gene. PubMed, Scopus, and Web of Science were searched for the identification of studies reporting cases of CPHD with FGFR1 gene defects.

RESULTS

Of the 648 records retrieved, 10 were included in this review. A comprehensive overview of the cases was summarized, and their clinical and genetic characteristics were presented.

CONCLUSION

Although FGFR1 variants have been associated with Kallmann syndrome and isolated hypogonadotropic hypogonadism and recently with CPHD, the patient's phenotype includes phenotypic alterations not previously described, to the best of our knowledge, within the spectrum of non-reproductive features of either of these entities. Isolated GH deficiency combined with other non-common abnormalities exerts a great possibility for subsequent CPHD manifestation.

Proposed Denosumab Biosimilar SB16 vs Reference Denosumab in Postmenopausal Osteoporosis: Phase 3 Results Up to Month 12

CONTEXT

SB16 is a proposed biosimilar to reference denosumab (DEN; brand name: Prolia).

OBJECTIVE

This phase 3 randomized, double-blind, multicenter study evaluated the biosimilarity of SB16 to DEN in women with postmenopausal osteoporosis (NCT04664959).

DESIGN

The study included 457 postmenopausal osteoporosis patients who had a lumbar spine or total hip T-score between -2.5 and -4. Patients were randomized in a 1:1 ratio to receive either 60 mg of SB16 or DEN subcutaneously at month 0 and month 6. At month 12, patients were rerandomized to continue with the assigned treatment or switch from DEN to SB16 up to month 18. This report includes results up to month 12.

METHODS

The primary endpoint was the percent change from baseline in lumbar spine bone mineral density (BMD) at month 12. Secondary endpoints including the percent change from baseline in BMD of the lumbar spine (except for month 12), total hip, and femoral neck; pharmacokinetic, pharmacodynamic (serum C-telopeptide of type I collagen, and procollagen type I N-terminal propeptide), safety, and immunogenicity profiles were measured up to month 12.

RESULTS

The least-squares mean differences in percent change from baseline in lumbar spine BMD at month 12 were 0.33% (90% CI, -0.25 to 0.91) in the full analysis set and 0.39% (95% CI, -0.36 to 1.13) in the per-protocol set; both within the predefined equivalence margin. The secondary endpoints were comparable between the 2 treatment groups.

CONCLUSION

The reported efficacy, pharmacokinetic, pharmacodynamic, safety, and immunogenicity data support the biosimilarity of SB16 to DEN.

Impact of menopause hormone therapy, exercise, and their combination on bone mineral density and mental wellbeing in menopausal women: a scoping review

Background

Osteoporosis, a condition marked by low bone mineral density (BMD) and structural deterioration, affects more women than men over 50 globally. In women, declining estrogen during the menopause accelerates bone resorption, heightening fracture risk. An association between osteoporosis and depression, frailty fractures and poor quality of life has been identified. Both menopause hormone therapy (MHT) and exercise are shown to improve BMD, with MHT reducing bone resorption and exercise promoting bone formation. This review examines the effectiveness of MHT, exercise, and their combination in managing menopausal osteoporosis.

Method

A multifactor scoping review was conducted to address osteoporosis and MHT, osteoporosis and exercise, and osteoporosis and MHT and exercise combined.

Results

Initial searches identified 15,158 studies, narrowed to 20 meeting the inclusion criteria. MHT and exercise are effective in preserving BMD in menopausal women. Combined estrogen and progesterone MHT is more effective than estrogen-only, with studies suggesting that MHT prescribed at low doses for longer durations more effectively preserves BMD. Resistance training (RT) completed 2-3 days per week at a moderate-to-high intensity combined with impact activity completed at a minimum of 3 days per week is optimal for improving BMD in menopausal women, while low-impact exercises provide supplemental benefits. Combining MHT with exercise enhances BMD more than either alone.

Conclusion

This review highlights that combining MHT and structured exercise is most effective for enhancing BMD in menopausal women. Given certain safety considerations surrounding MHT in some women, exercise remains a cornerstone for the prevention and management of osteoporosis as well as for promoting overall wellness.

Effect of abaloparatide on fracture incidence and bone mineral density in postmenopausal women with osteoporosis at highest risk for fracture

OBJECTIVE

This post hoc analysis evaluated the efficacy of abaloparatide treatment in a subgroup of postmenopausal women from the Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE; NCT01343004) study who met high fracture risk criteria (defined in several professional society guidelines).

METHODS

Women from ACTIVE meeting ≥1 of the following fracture risk criteria were included: fracture within the past 12 months or prevalent vertebral fracture, baseline T score of <-3.0 at any site, very high fracture risk probability by FRAX (ie, 10-yr major osteoporotic fracture >30% or hip fracture >4.5%), or multiple prior fractures at baseline since age ≥45 years.

RESULTS

A total of 2,026 participants met ≥1 fracture risk criteria defined in clinical guidelines (abaloparatide, n = 664; placebo, n = 677; teriparatide, n = 685). New vertebral fracture risk was reduced in participants receiving abaloparatide (4 [0.72%]) and teriparatide (6 [0.99%]) versus placebo (28 [4.77%]; both P  < 0.0001). Estimated Kaplan-Meier cumulative incidence of nonvertebral fracture was 3.0%, 5.3%, and 3.0% in the abaloparatide, placebo, and teriparatide groups, respectively; 4.0%, 9.0%, 4.3% for clinical fracture; 1.6%, 6.8%, 3.0% for major osteoporotic fractures; and 1.1%, 2.1%, 2.1% for wrist fracture. Abaloparatide was associated with bone mineral density gains from baseline at the lumbar spine, total hip, and femoral neck at all time points (6, 12, and 18 mo; P  < 0.0001 for all). Common adverse events reported in participants treated with abaloparatide were hypercalciuria (11.5%), dizziness (11.0%), and arthralgia (8.9%).

CONCLUSIONS

Abaloparatide reduced fracture incidence and increased bone mineral density in participants at highest fracture risk, consistent with the overall ACTIVE study.

Challenges in Gaucher disease: Perspectives from an expert panel

This focused review concentrates on eight topics of high importance for Gaucher disease (GD) clinicians and researchers: 1) The consideration of GD as distinct types rather than a spectrum. A review of the literature clearly supports the view that there are distinct types of GD. Type 1 is characterized by the absence of primary neuronopathic involvement, while types 2 and 3 are characterized by progressive primary neuronopathic disease. 2) Neurologic and neuronopathic manifestations. A growing body of evidence indicates that the peripheral nervous system may be involved in GD type 1 and that there may also be signs and symptoms of central nervous system (CNS) disease in this group. However, GD type 1 is characterized by the absence of primary neuronopathic disease, whereas GD types 2 and 3 are characterized by progressive, albeit variable, primary neuronopathic disease. Abnormalities in saccadic eye movements have been suggested as being diagnostic for neuronopathic GD, but they may also occur in GD type 1 and in other inflammatory diseases. 3) The importance of whole GBA1 sequencing. This approach is superior to exome sequencing because of potential effects of deep intronic variants on gene expression. It also has the capacity to detect variant alleles that might be missed with gene panels. 4) Monoclonal gammopathy of undetermined significance (MGUS). The risks of MGUS, multiple myeloma, and non-Hodgkin's lymphoma are elevated in patients with GD compared to the general population and strong evidence indicates that lyso-Gb1 stimulates the formation of monoclonal immunoglobulins (M-protein) in patients with GD and MGUS. 5) Pulmonary involvement in GD. Pulmonary complications can be identified through spirometry in up to 45 % of patients with GD type 1 and 55 % of those with GD type 3. Limited evidence exists that enzyme replacement therapy (ERT) reduces the severity of these complications in patients with GD type 1. 6) Gaucheromas. These may occur in patients with GD types 1 or 3, but there is little detailed information about their inception, mechanisms underlying growth, cellular organization, and biochemical activities, and no definitive guidance for their management. Gaucheromas behave like benign (i.e. non-metastasizing) neoplasms, and it may be reasonable to classify them as such. 7) Bone and joint involvement. Dual-energy X-ray absorptiometry scans alone are insufficient for monitoring all changes in bone that may occur in patients with GD. Quantitative magnetic resonance imaging (MRI) techniques using Dixon quantitative chemical shift imaging have provided results that correlate with GD severity scores, bone complications, and biomarkers for GD bone involvement. Thoracic kyphosis is a common complication of GD types 1 and 3, and there is very limited information regarding the effects of ERT or substrate synthesis inhibition therapy (SSIT) on this condition. 8) Treatment initiation, selection, combination, and switching. Prompt initiation of treatment in pediatric patients is important as GD can lead to impaired growth, lower peak bone mass, and delayed puberty. These adverse outcomes can often be ameliorated or prevented with timely treatment. Either ERT or eliglustat, a SSIT agent, is suitable as first-line treatment of adults with GD. Studies of switching from ERT to eliglustat, or between different ERT products, have indicated that changing treatment is safe, although efficacy outcomes vary. A critical remaining issue is the lack of treatments capable of reaching the CNS to slow or halt the progression of neuronopathic disease in patients with GD type 2 or 3 and potentially reduce the risk of Parkinson's disease in GD type 1 patients and heterozygotes for GBA1 variants.

Re-engineering bone: pathogenesis, diagnosis and emerging therapies for osteoporosis

Osteoporosis, a multifaceted metabolic bone disease, is becoming increasingly prevalent and poses a significant burden on global healthcare systems. Given the limitations of traditional treatments such as pharmacotherapy, tissue engineering has emerged as a promising alternative for osteoporosis management. This review begins by exploring the pathogenesis of osteoporosis, with a focus on the abnormal metabolic, cellular, and molecular signalling microenvironments that drive the disease. We also examine commonly used clinical diagnostic techniques, discussing their strengths and limitations. Notably, this review evaluates various advanced tissue engineering strategies for osteoporosis treatment. Delivery systems, including injectable hydrogels and nanomaterials, are detailed alongside bone tissue engineering materials such as bioactive ceramics, bone cements, and polymers. Additionally, biologically active substances, including exosomes and cytokines, and emerging therapies that leverage small-molecule drugs are explored. Through a comprehensive analysis of the advantages and limitations of current biomaterials and therapeutic approaches, this review provides insights into future directions for tissue engineering-based solutions. By synthesizing current advancements, it aims to inspire innovative perspectives for the clinical management of osteoporosis.

A comprehensive review and advanced biomolecule-based therapies for osteoporosis

BACKGROUND

The prevalence of osteoporosis (OP) on a global scale is significantly elevated that causes life threatening issues. The potential of groundbreaking biomolecular therapeutics in the field of OP is highly encouraging. The administration of biomolecular agents has the potential to mitigate the process of bone demineralization while concurrently augmenting the regenerative capacity of bone tissue, thereby facilitating a personalized therapeutic approach. Biomolecules-based therapies showed promising results in term of bone mass protection and restoration in OP.

AIM OF REVIEW

We summarized the recent biomolecular therapies with notable progress in clinical, demonstrating the potential to transform illness management. These treatments frequently utilize different biomolecule based strategies. Biomolecular therapeutics has a targeted character, which results in heightened specificity and less off-target effects, ultimately leading to increased patient outcomes. These aspects have the capacity to greatly enhance the management of OP, thus resulting in a major enhancement in the quality of life encountered by individuals affected by this condition.

Impact of social determinants on osteoporosis treatment and secondary fracture risk after primary fragility fractures

This study examined the impact of social determinants of health (SDOH) on osteoporosis management and secondary fractures after primary fragility fractures. Despite similar osteoporosis treatment rates between patients with and without adverse SDOH, patients with adverse SDOH experienced significantly higher secondary fracture rates, highlighting the need for targeted interventions to improve post-fracture care in socioeconomically disadvantaged populations.

PURPOSE

Osteoporosis is a global health concern affecting over 500 million people. Fragility fractures are often the first indication of osteoporosis and are associated with significant morbidity and mortality. While low socioeconomic status is associated with increased risk of fragility fractures, the impact of social determinants of health (SDOH) on osteoporosis treatment and secondary fracture rates following primary fragility fractures remains unclear.

METHODS

Patients aged 50 and older who sustained primary fragility fractures and had no prior osteoporosis treatment were identified using a large national database. Patients were stratified by the presence of adverse SDOH. Kaplan-Meier and multivariate Cox proportional hazards regression analyses were performed to evaluate the cumulative incidence of osteoporosis treatment within 1 year (including bisphosphonates, biologics, parathyroid hormone analogs, estrogens, and selective estrogen receptor modulators) and rates of secondary fractures within two years.

RESULTS

A total of 276,845 patients were included in this study. Overall, 4.4% of patients with adverse SDOH and 5.3% of patients without were prescribed osteoporosis treatment within a year of fracture; however, this difference was not significant after controlling for confounders (hazard ratio (HR) 0.98; P = 0.82). Patients with adverse SDOH had significantly higher rates of secondary fractures within 2 years (7.4% versus 6.0%; HR 1.29; P < 0.001).

CONCLUSION

Adverse SDOH were associated with increased rates of secondary fractures among patients with primary fragility fractures, despite similar osteoporosis management rates between groups. Overall, osteoporosis treatment rates remain low. Targeted strategies to optimize secondary prevention and tailored interventions are needed, particularly for socioeconomically disadvantaged populations.

Implementing a Clinical Risk Assessment Tool to Improve Bone Health in Postmenopausal Women

OBJECTIVE

To improve staff knowledge of osteoporosis and increase the identification of fracture risk in postmenopausal women by implementing use of the Fracture Risk Assessment Tool (FRAX) in an outpatient setting.

DESIGN

Quality improvement project guided using the Plan-Do-Study-Act cycle.

SETTING/LOCAL PROBLEM

In a low-income primary care clinic, no standardized fracture risk assessment tool was being used, leading to inconsistency in referrals for dual-energy X-ray absorptiometry (DXA).

PARTICIPANTS

Office staff and postmenopausal women ages 50 to 64 years.

INTERVENTIONS/MEASUREMENTS

A standardized process was designed to promote appropriate osteoporosis management to improve the assessment, diagnosis, and treatment of osteoporosis in postmenopausal women. Staff training was provided before project implementation. Outcome measures included pre-post Revised Osteoporosis Knowledge Test, FRAX adherence, and DXA referrals.

RESULTS

Staff knowledge improved by 25.8% after completion of staff training. During the 2-month implementation period, FRAX adherence was 96.3% (n = 156) among the 162 eligible women, and 98.6% of DXA referrals (n = 70) were completed for the 71 women identified with a major osteoporotic fracture risk greater than 8.4%.

CONCLUSION

With this quality improvement project, we successfully implemented the FRAX tool in the outpatient setting. Initial high adherence rates for FRAX screenings and DXA referrals demonstrated advancements made in clinical practice to provide evidence-based care to postmenopausal women at the greatest risk for an osteoporotic fracture.

Comparative analysis of ChatGPT-4o mini, ChatGPT-4o and Gemini Advanced in the treatment of postmenopausal osteoporosis

BACKGROUND

Osteoporosis is a sex-specific disease. Postmenopausal osteoporosis (PMOP) has been the focus of public health research worldwide. The purpose of this study is to evaluate the quality and readability of artificial intelligence large-scale language models (AI-LLMs): ChatGPT-4o mini, ChatGPT-4o and Gemini Advanced for responses generated in response to questions related to PMOP.

METHODS

We collected 48 PMOP frequently asked questions (FAQs) through offline counseling and online medical community forums. We also prepared 24 specific questions about PMOP based on the Management of Postmenopausal Osteoporosis: 2022 ACOG Clinical Practice Guideline No. 2 (2022 ACOG-PMOP Guideline). In this project, the FAQs were imported into the AI-LLMs (ChatGPT-4o mini, ChatGPT-4o, Gemini Advanced) and randomly assigned to four professional orthopedic surgeons, who independently rated the satisfaction of each response via a 5-point Likert scale. Furthermore, a Flesch Reading Ease (FRE) score was calculated for each of the LLMs' responses to assess the readability of the text generated by each LLM.

RESULTS

When it comes to addressing questions related to PMOP and the 2022 ACOG-PMOP guidelines, ChatGPT-4o and Gemini Advanced provide more concise answers than ChatGPT-4o mini. In terms of the overall FAQs of PMOP, ChatGPT-4o has a significantly higher accuracy rate than ChatGPT-4o mini and Gemini Advanced. When answering questions related to the 2022 ACOG-PMOP guidelines, ChatGPT-4o mini vs. ChatGPT-4o have significantly higher response accuracy than Gemini Advanced. ChatGPT-4o mini, ChatGPT-4o, and Gemini Advanced all have good levels of self-correction.

CONCLUSIONS

Our research shows that Gemini Advanced and ChatGPT-4o provide more concise and intuitive answers. ChatGPT-4o responds better in answering frequently asked questions related to PMOP. When answering questions related to the 2022 ACOG-PMOP guidelines, ChatGPT-4o mini and ChatGPT-4o responded significantly better than Gemini Advanced. ChatGPT-4o mini, ChatGPT-4o, and Gemini Advanced have demonstrated a strong ability to self-correct.

CLINICAL TRIAL NUMBER

Not applicable.

Mechanistic Integration of Network Pharmacology and In Vivo Validation: TFRD Combat Osteoporosis via PI3K/AKT Pathway Activation

In the context of osteoporosis closely linked to bone metabolism imbalance caused by estrogen deficiency, total flavonoids of Rhizoma Drynariae (TFRD) exhibit potential anti-osteoporotic activity, yet their multicomponent synergistic mechanism and association with the PI3K/AKT signaling pathway remain unclear. This study aimed to systematically elucidate the molecular mechanisms by which TFRD regulate bone metabolism and improve osteoporosis in ovariectomized (OVX) rats through the PI3K/AKT pathway, integrating network pharmacological predictions with animal experimental validation. Methods involved identifying TFRD's active components using UPLC/MS-MS, predicting targets with SwissTargetPrediction, constructing a "component-target-disease" network, and performing GO/KEGG enrichment analysis with MetaScape (v3.5). In vivo experiments established an OVX rat model, randomized into sham, OVX, low-/high-dose TFRD, and sim groups, assessing bone mineral density (BMD) and mandibular Micro-CT parameters after 12 weeks. Western blot analyzed PI3K, p-AKT1, and related protein expressions. Results showed the high-dose TFRD group significantly increased BMD, improved trabecular bone quantity and structure, and upregulated PI3K, p-PI3K, and p-AKT1 protein expressions compared to the OVX group. Molecular docking confirmed stable binding energy between core components and PI3K/AKT targets. TFRD may ameliorate estrogen deficiency-induced osteoporosis by activating the PI3K/AKT signaling pathway, inhibiting bone resorption, and promoting osteogenic differentiation, providing pharmacological evidence for multitarget treatment of osteoporosis with traditional Chinese medicine.

A Hip New Standard: Improving Osteoporosis Care with Inpatient Administration of IV Zoledronate

BACKGROUND

Osteoporosis continues to be underdiagnosed and inadequately treated in older hip-fracture patients. Our aim was to improve the rate of osteoporosis treatment with IV bisphosphonate therapy in eligible patients admitted for hip-fracture surgery.

METHODS

The present study was designed as a quality improvement initiative using Plan-Do-Study-Act (PDSA) cycles at an academic medical center in Portland, Oregon, over 2.5 years. A protocol was developed (1) to administer IV zoledronate on postoperative day 2 to inpatients aged ≥50 years who underwent surgery for a low-energy hip fracture and (2) to formally diagnose osteoporosis during admission. The protocol was introduced across 3 care settings in a stepped-wedge manner. Outcome measures were the percentage of inpatient zoledronate administered to eligible patients and formal documented diagnosis of osteoporosis. Balance measures included fever after administration and hospital length of stay (LOS). Measures were assessed through quarterly chart review and tracked via control charts.

RESULTS

The rate of zoledronate administration significantly increased from 34.5% (29 of 84) to 74.6% (53 of 71) following the second PDSA cycle (p < 0.001). Documented osteoporosis diagnosis also significantly improved from 51.0% (53 of 104) to 85.7% (96 of 112) following the second PDSA cycle (p < 0.001). No significant differences were shown for hospital LOS, and 1 of 82 patients had medical work-up for post-infusion acute phase reaction after administration.

CONCLUSIONS

This initiative was effective at improving osteoporosis diagnosis and treatment among older hip-fracture patients at our institution. Protocol development for administrating inpatient zoledronate after hip fracture is a reliable way to predictably offer bone health care and secondary-fracture prevention to hip-fracture patients and can be adapted and implemented at other institutions.

LEVEL OF EVIDENCE

Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Associations of the serum 25-hydroxyvitamin D with mortality among patients in osteopenia or osteoporosis

PURPOSE

The correlation between serum 25-hydroxy vitamin D [(25(OH)D] and mortality in patients with osteopenia or osteoporosis remains unclear. Therefore, this study examined the relationship between serum 25(OH)D and mortality in patients with osteopenia or osteoporosis.

METHODS AND RESULTS

This prospective cohort study included patients with osteopenia or osteoporosis from the National Health and Nutrition Examination Survey from 2001 to 2018. Multivariate Cox regression models examined the correlation between serum 25(OH)D and all-cause mortality, cardiovascular mortality (CVD), and cancer mortality. The cohort included 9282 adult participants with a median follow-up period of 97.01 months, including 1394 all-cause deaths, 413 CVD-related deaths, and 322 cancer deaths. In fully adjusted models, higher serum 25(OH)D levels (≥75.0 nmol/L) were associated with a lower risk of all-cause mortality (hazard ratio 0.54, 95 % confidence interval 0.41 to 0.73) and cardiovascular death (0.47, 0.29 to 0.76), using participants with low 25(OH)D levels (<25 nmol/L) as the reference. In addition, we found an L-shaped non-linear dose-response relationship between serum 25(OH)D and all-cause and cardiovascular mortality, with inflection points of 38.8 nmol/L and 53.6 nmol/L, respectively.

CONCLUSION

Higher serum 25(OH)D concentrations are strongly associated with a diminished risk of all-cause and CVD mortality in patients with osteopenia or osteoporosis. This association has a threshold effect. More in-depth intervention studies are needed to clarify underlying mechanisms.

A Sex Comparison of Fall and Fracture Occurrence in the Elderly Diabetic Population: A Quantitative Study

Aims

To assess differences in falls and fractures in men and women with type 2 diabetes mellitus (T2DM) within a diverse population in Southeast Louisiana.

Methods

A list of 1200 patients was generated through an electronic health record system using keywords: diabetic diagnosis, falls, and fractures to conduct this retrospective cohort study. This chart review included adults with T2DM who experienced at least one fall and/or fracture between January 2018 and May 2023 at East Jefferson General Hospital located in Metairie, Louisiana. Only falls and fractures that resulted in a hospital visit were included. Results were compared between males and females.

Results

Patient data were collected from 100 randomly selected patients: 50 females and 50 males (mean age 67 years, 97% of patients were non-Hispanic, and 72% Black). Statistical analysis was conducted using the Student's t test, Fisher's exact, and Pearson correlation. An average of 3-4 falls occurred per patient, with no significant sex difference observed (p = 0.97). Thirty-eight percent of patients experienced a fracture with a significant sex difference (50% of female vs. 26% of male patients [p = 0.02]). Positive correlations between comorbid conditions and falls and fractures were seen, particularly in women: a moderate correlation for falls (r = 0.48, p < 0.01) and a strong correlation for fractures (r = 0.52, p < 0.01). Patients not on insulin treatment experienced a greater occurrence of fractures than insulin-dependent patients (46% vs. 22%, p = 0.03).

Conclusions

Our findings suggest that in a diverse population, women with T2DM are at an increased risk of experiencing fractures, and specialized care should be given to this population to reduce the risk of fracture occurrence. Additional comorbidities increase the risk of falls and fractures.

Romosozumab for the treatment of osteoporosis - a systematic review

INTRODUCTION

Romosozumab, a new treatment of osteoporosis, is a monoclonal antibody that targets sclerostin and thereby exhibits a dual mechanism of action by stimulating bone formation and inhibiting bone resorption. This systematic review aims to assess the clinical efficacy and safety of romosozumab for treatment of primary and secondary osteoporosis.

METHODS

A comprehensive literature search was conducted in October 2023 across multiple databases including Embase, PubMed and Cochrane Library. Randomized controlled trials (RCTs) and observational studies evaluating the impact of romosozumab on BMD, bone turnover markers (BTM), fracture outcomes, and its safety profile were included. Data extraction and quality assessment were performed independently by two reviewers in accordance with PRISMA guidelines.

RESULTS

A total of 36 articles met the inclusion criteria. Romosozumab significantly increased BMD at the lumbar spine, total hip, and femoral neck compared to placebo and active comparators in patients with primary osteoporosis. Sequential therapy with romosozumab followed by antiresorptives maintained or further increased BMD and reduced fracture risk. Romosozumab was generally well tolerated, however, an imbalance in cardiovascular adverse event was observed in one large clinical trial. Observational studies supported these findings. Specific subgroups of patients with secondary osteoporosis were assessed, demonstrating overall positive outcomes with romosozumab treatment.

CONCLUSION

Romosozumab effectively increases BMD and reduces fracture risk, particularly when used as initial therapy in high fracture-risk patients. Sequential therapy with subsequent antiresorptive treatment optimizes long-term benefits. While generally well-tolerated, its cardiovascular safety profile requires further long-term studies to ensure its safety in clinical practice. Additional studies are needed to confirm efficacy and safety in patients with secondary osteoporosis.

Factors associated with rod fracture following surgery for adult spinal deformity: a single-center retrospective study

PURPOSE

Adult spinal deformity (ASD) has a significant impact on trunk balance and quality of life in the elderly. Postoperative rod fractures pose significant challenges, but the mechanisms of their occurrence are underexplored compared to other complications such as proximal junctional kyphosis. This study investigated factors associated with rod fracture in patients with ASD.

METHODS

A retrospective single-center study analyzed 110 adult patients who underwent spinal deformity correction between 2012 and 2020. Comparative analysis and univariate and multivariate Cox regression analyses were employed to identify factors associated with rod fracture.

RESULTS

In this study, rod fracture occurred in 14.5% of patients. The rod fracture group exhibited a larger change in lumbar lordosis (LL), a higher proportion of patients with pre-operatively existing (pre-existing) vertebral fractures, and a greater percentage of patients with a rod diameter of 6 mm or less compared to the non-rod fracture group. Univariate Cox regression analysis revealed that rod fracture was associated with pre-existing vertebral fracture, LL change, preoperative sagittal vertical axis, and preoperative pelvic tilt. Multivariate Cox regression analysis identified pre-existing vertebral fractures and the amount of LL change as independent factors associated with rod fractures.

CONCLUSION

Pre-existing vertebral fractures and the magnitude of lumbar lordosis correction are independent risk factors for rod fracture following ASD surgery. Surgeons should consider these factors during preoperative planning to reduce the risk of postoperative rod fracture.

LEVEL OF EVIDENCE

IV.

Evidence-based joint statement position of perioperative bone optimization in the arthroplasty candidate, from FEMECOT, AMMOM, ACOMM, SCCOT, SECOT, SEFRAOS, SEIOMM

BACKGROUND

The prevalence of patients living with joint replacements is increasing. Nearly two-thirds of patients undergoing elective arthroplasty procedures have low bone mineral density (LBMD), defined as osteopenia in 38.5% and osteoporosis in 24.8%; among those with osteoporosis, only 32.8% received treatment at the time of surgery.

MATERIALS AND METHODS

A group of 7 national societies (FEMECOT, AMMOM, ACOMM, SCCOT, SECOT, SEFRAOS, SEIOMM) developed a joint statement position on the diagnosis of osteoporosis and perioperative bone optimization in candidates for arthroplasty "Arthroplasty Bone Optimization." We performed a scoping review of the available literature, followed by a systematic review and meta-analysis. Subsequently, a Delphi-modified method was used to gather the different positions.

RESULTS

After analyzing the literature, we came up with five recommendations: (1) Patients scheduled for elective arthroplasty should undergo a bone health assessment (BHA). (2) If poor bone quality is observed during surgery and a bone health assessment has not been conducted promptly, a complete BHA, including a DXA scan, is imperative. (3) In the arthroplasty candidate, if LBMD or osteoporosis are noticed, bone loss-related factors should be corrected, and appropriate treatment for osteoporosis should be started before or right after arthroplasty. The use of anti-resorptive and bone anabolic agents has been shown to reduce periprosthetic bone loss, complications, and non-septic revision rates after joint arthroplasty. (4) In arthroplasty candidates, the diagnosis of osteoporosis or low bone mineral density (LBMD) should not delay the surgery. (5) Monitoring central and periprosthetic bone mineral density through DXA protocols can help identify bone loss in central and periprosthetic areas in patients with risk factors or osteoporosis.

CONCLUSIONS

Perioperative bone optimization should be considered in all patients who are candidates for arthroplasty. The orthopedic surgeon and multidisciplinary team should be encouraged to diagnose and treat the arthroplasty candidates' bone by screening for bone loss-related factors and diagnosing osteoporosis and starting treatment according to the current international guidelines. Following these recommendations could reduce periprosthetic bone loss, complications, and aseptic revision rates following arthroplasty surgery. More research is needed to understand the implications of osteoporosis and its treatment for joint replacement outcomes and long-term survival.

Bisphosphonates Maintain BMD After Sequential Teriparatide and Denosumab in Premenopausal Women with Idiopathic Osteoporosis

CONTEXT

We previously reported that sequential teriparatide followed by denosumab substantially increases bone mineral density (BMD) in premenopausal idiopathic osteoporosis (PremenIOP).

OBJECTIVE

To determine whether administration of bisphosphonates after denosumab cessation is associated with stable BMD in PremenIOP.

DESIGN

Open-label extension study.

PARTICIPANTS

Twenty-four PremenIOP Teriparatide-Denosumab Study participants.

INTERVENTIONS

Oral alendronate (ALN), 70 mg weekly, or intravenous zoledronic acid (ZOL), 5 mg once (patient choice), was administered 7 months (M) after final denosumab dose.

OUTCOMES

BMD by dual-energy x-ray absorptiometry and serum C-telopeptide (CTX) q6M; Vertebral Fracture Assessment (VFA), and high-resolution peripheral quantitative computed tomography (HR-pQCT) q12 M.

RESULTS

Twenty-four women with PremenIOP (aged 43 ± 8 years), severely affected with low trauma adult fractures (range 0-12; 9 with vertebral fractures) and/or very low BMD, had large BMD increases on sequential teriparatide-denosumab (spine: 25 ± 9%; total hip: 11 ± 6%). During the Bisphosphonate Extension, mean BMD and CTX changes in the entire group were small and not statistically significant at 6 or 12 M.Women choosing ZOL (n = 6) vs ALN (n = 18) did not differ by baseline age, body mass index, fractures, BMD, or CTX. On ZOL, there were small lumbar spine BMD declines and CTX increases, particularly between 6 M and 12 M, while greater stability was observed on ALN.Changes in BMD and CTX did not differ by duration of denosumab (36 M vs <36 M) or between 20 women who remained premenopausal and 4 who transitioned into menopause. Higher pre-teriparatide CTX, likely reflecting baseline remodeling status, predicted more spine and hip bone loss. No new vertebral (clinical or vertebral fraction assessment screening) or nonvertebral fractures occurred.

CONCLUSION

BMD remained stable in women with PremenIOP who received bisphosphonates after sequential teriparatide-denosumab therapy.

A rapid method for the preparation of an in vitro osteoporosis model of calf vertebrae: histological and biomechanical study

Background

In vitro biomechanical testing is crucial for the preclinical assessment of novel implant designs. Given the constraints of limited supply and high costs associated with human specimens, calf spines are frequently employed as surrogates for human spines in both in vivo and in vitro biomechanical studies.

Methods

This study selected 60 spinal vertebrae from calves aged between 12 and 18 weeks. The specimens were randomly assigned to two treatment groups, A and B, each comprising 30 specimens. Group A served as the control without decalcification, while Group B underwent decalcification using an 18.3% ethylene diamine tetraacetic acid solution. The impact of decalcification was assessed through histological, imaging, and biomechanical analyses.

Findings

Decalcification took approximately 2 months, resulting in osteoporotic vertebrae with a bone mineral density reduction of approximately 50.89% compared to pre-decalcification levels. The bone microstructure was significantly altered, characterized by a decrease in trabecular thickness and number and an increase in trabecular separation. Additionally, the trabecular bone pattern factor (TBPf) and Structure Model Index (SMI) increased. The modulus of elasticity, yield stress, and ultimate stress of the vertebral bodies were all reduced in correlation with the decrease in bone mineral density, demonstrating a strong correlation between these parameters.

Interpretation

The data from this study indicate that the decalcification method is effective and capable of rapidly establishing an osteoporotic model suitable for biomechanical testing of clinical devices. This method offers the benefits of ease of operation, reliability, and a controllable degree of osteoporosis.

The effect of denosumab on minimum 3-years BMD changes in patients with osteoporotic hip fractures: a propensity score matching analysis

Denosumab significantly increased lumbar spine and total hip bone mineral density in patients with hip fractures, with comparable efficacy to that in other than hip fracture patients. Its effect was more pronounced in medication-naïve patients, suggesting its efficacy regardless of hip fracture status.

PURPOSE

Denosumab, a potent antiresorptive agent, has been recognised to increase bone mineral density (BMD) and reduce fracture risk in vertebrae and hips. Despite its widespread use, no sequential follow-up studies have investigated its effects on BMD in patients with hip fractures. This study aimed to analyse the effect of denosumab on BMD gain in patients with hip fractures and investigate the incidence of subsequent hip fractures.

METHODS

This retrospective study analysed 371 patients treated with denosumab for at least 3 years, including 122 patients with hip fractures. 1:1 propensity score matching was used to compare BMD changes in the lumbar spine, total hip, and femoral neck, as well as additional hip fracture incidence between the hip fracture and the other than hip fracture group. Ultimately, 122 patients in each group were compared. Subgroup analysis compared osteoporosis medication-naïve patients with those with prior medication use.

RESULTS

The hip fracture and other than hip fracture group exhibited significant annual increases in lumbar spine and total hip BMD, with no significant differences between them after matching. The femoral neck BMD increased significantly only in the first year. The incidence of additional hip fractures did not differ significantly between the groups. Moreover, the effect of denosumab on BMD increase was more pronounced in patients without a previous medication history for anti-osteoporosis treatment than in those with such a history.

CONCLUSION

Denosumab significantly increased lumbar spine and total hip BMD in patients with hip fractures, with comparable efficacy to that in other than hip fracture patients. Its effect was more pronounced in medication-naïve patients, suggesting its efficacy regardless of hip fracture status.

The impact of a fracture liaison service with in-hospital anti-osteoporosis treatment on subsequent hip fracture and mortality rates-a single-center retrospective study

The implementation of an in-hospital fracture liaison service facilitated prompt initiation of anti-osteoporosis treatment following a hip fracture (HF), increasing follow-up and treatment rates. This led to a 48% reduction in the risk of subsequent HF and a 29% decrease in mortality rates.

PURPOSE

To demonstrate the impact of an institutional fracture liaison service (FLS) which allowed in-hospital anti-osteoporosis treatment following hip fracture (HF) on subsequent HF and mortality rate.

METHODS

We retrospectively evaluated patients aged 65 years and older, admitted with an osteoporotic HF, who were transferred following surgery for rehabilitation in the geriatrics department in two time periods: before and after the implementation of an institutional FLS ("geriatric-pre-FLS" and "geriatric-FLS" cohorts, respectively). Data were captured from electronic records and the two cohorts were compared following an assessment of baseline characteristics, follow-up, and anti-osteoporosis treatment initiation. A multivariable Cox regression model evaluated differences between the cohorts regarding subsequent HF and mortality rates.

RESULTS

Three hundred and eighteen and 448 patients comprised the geriatric-pre-FLS (07/2008-06/2014) and the geriatric-FLS (03/2016-03/2020) cohorts, respectively. Baseline characteristics were comparable between the cohorts (median age 81 vs. 82, p = 0.08 and female sex 73% vs. 70%, p = 0.48, respectively). Rates of endocrine consultation (3.5% vs. 99%%, p < 0.001), DXA-BMD testing (7.5% vs. 34%, p < 0.001), and parenteral anti-osteoporosis treatment (4% vs. 76.6%, p < 0.001) were all higher in the geriatric-FLS cohort. The implementation of the FLS led to a 48% reduction in subsequent HF risk (HR 0.52; 95% CI 0.37-0.74, p < 0.001) and a 29% decrease in mortality rate (HR 0.71; 95% CI 0.54-0.92, p = 0.011).

CONCLUSIONS

The implementation of an in-hospital FLS facilitated prompt initiation of anti-osteoporosis treatment following a HF, increased follow-up and treatment rates, and resulted in a 48% reduction in subsequent HF risk and a 29% reduction in mortality rates.

Long-Term Efficacy and Safety of Denosumab: Insights beyond 10 Years of Use

Osteoporosis management in post-menopausal women focuses on fracture prevention, with denosumab as a key therapeutic option. Despite its proven efficacy in reducing fracture risk and increasing bone mineral density (BMD) over 10 years, its long-term impact remains uncertain. We evaluated the literature on its efficacy and safety beyond the initial decade. Clinical trials and real-world studies confirm denosumab's sustained efficacy, especially in lumbar spine BMD, with hip BMD stabilizing. Concerns about adverse events (AEs) like hypocalcemia and osteonecrosis of the jaw necessitate vigilant monitoring. Risks of atypical femoral fractures and malignancies also require attention, despite unclear links to treatment duration. Clinical guidelines for denosumab beyond 10 years are limited, emphasizing the need for careful monitoring. In certain scenarios, such as advanced chronic kidney disease, prolonged denosumab may be required to balance AE risks with fracture prevention benefits. Denosumab shows potential for long-term efficacy in augmenting BMD; however, monitoring for AEs is crucial to guide clinical decision-making effectively.

Current and emerging bone resorption inhibitors for the treatment of osteoporosis

INTRODUCTION

Osteoporosis is a metabolic skeletal disease characterized by low bone mass and strength, and increased risk for fragility fractures. It is a major health issue in aging populations, due to fracture-associated increased disability and mortality. Antiresorptive treatments are first line choices in most of the cases.

AREAS COVERED

Bone homeostasis is complicated, and multiple factors can compromise skeletal health. Bone turnover is a continuous process regulated by the coupled activities of bone cells that preserves skeletal strength and integrity. Imbalance between bone resorption and formation leads to bone loss and increased susceptibility to fractures. Antiresorptives prevent bone loss and reduce fracture risk, by targeting osteoclastogenesis and osteoclast function and survival. Their major drawback is the coupling of osteoclast and osteoblast activity, due to which any reduction in bone resorption is followed by suppression of bone formation.

EXPERT OPINION

During the last couple of decades significant progress has been made in understanding of the genetic and molecular basis of osteoporosis. Critical pathways and key molecules that mediate regulation of bone resorption have been identified. These factors may underpin novel therapeutic avenues for osteoporosis, but their potential for translation into clinical applications is yet to be tested.

Comparative Effectiveness of Abaloparatide and Teriparatide in Women 50 Years of Age and Older: Update of a Real-World Retrospective Analysis

BACKGROUND

Abaloparatide and teriparatide are osteoanabolic treatments indicated for postmenopausal women and men with osteoporosis at high risk of fracture. In the Abaloparatide Comparator Trial In Vertebral Endpoints study, bone mineral density improvements were significantly greater with abaloparatide compared to teriparatide at the total hip and femoral neck. We conducted a retrospective claims study to examine the incidences of hip and nonvertebral fractures and cardiovascular events in women aged ≥50 years initiating abaloparatide or teriparatide therapy, expanding on a previous retrospective claims study.

METHODS

This retrospective observational study used anonymized claims data from ICON's Symphony Health, PatientSource for women aged ≥ 50 years with ≥ 1 prescription fill for abaloparatide or teriparatide. The index date was the date of the initial prescription dispensed. Times to first hip fracture, nonvertebral fracture, and serious cardiovascular event were compared between logistic regression-based propensity score-matched cohorts and in predefined subgroups by age, prior antiresorptive use, and prior fracture using Cox proportional hazards models.

RESULTS

Patients (21 676 per cohort) were well matched on 73 baseline parameters. Forty-five percent of patients in the abaloparatide arm and 47% in the teriparatide arm were exposed to treatment for longer than 12 months. Over 18 months (+ 30 days follow-up), 245 (1.1%) and 296 (1.4%) women in the abaloparatide and teriparatide cohorts, respectively, had a hip fracture (HR [95% CI] 0.83 [0.70, 0.98]; P = .027); 947 (4.4%) and 1078 (5.0%) had a nonvertebral fracture (0.88 [0.80, 0.96]; P = .003). There were no significant treatment-subgroup interactions (P ≥ .2). Cardiovascular events were similar between groups.

CONCLUSIONS

There were significantly lower rates of hip and nonvertebral fractures with abaloparatide compared to teriparatide, which were consistent across subgroups. No differences in cardiovascular safety were noted between cohorts.

Effects of denosumab and zoledronic acid on postmenopausal osteoporosis, bone density, and fat-free mass

This study compared denosumab and zoledronic acid for treating osteoporosis in drug-naïve postmenopausal Korean women. Over 3 years, both drugs significantly increased bone mineral density. However, denosumab also improved fat-free mass, suggesting it may be a better initial treatment for osteoporosis with low muscle mass, assuming all other conditions remain constant.

BACKGROUND

Denosumab (DMAB) and zoledronic acid (ZOL), which are strong antiresorptive agents, are used to treat osteoporosis in postmenopause. Nonetheless, the data on their comparative efficacy in drug-naïve patients remain limited. Our research compared the therapeutic efficacy of DMAB and ZOL in drug-naïve postmenopausal Korean women with osteoporosis.

METHODS

In total, 120 women were enrolled and equally divided to the DMAB and ZOL groups. The bone density and biochemical parameters of the patients were monitored over 3 years. Furthermore, the changes in fat-free mass (FFM), which comprises muscle mass, were assessed by bioelectric impedance analysis. Baseline characteristics, including age, BMI, and the prevalence of fractures, were similar between the groups at the onset of the study. Serum 25(OH), calcium and, phosphorus levels and baseline bone mineral density (BMD) were also comparable between the groups.

RESULTS

Following 3 years of treatment, both groups exhibited a significant increase in BMD versus the baseline value. In particular, BMD increased by 9.7% and 5.1% at the lumber spine and total hip, respectively, in the DMAB group, versus increases of 7.1% and 4.4%, respectively, in the ZOL group. The increase in FFM was greater in the DMAB group. BMI-adjusted FFM decreased by 1.3% in the ZOL group, versus an increase of 3.6% in the DMAB group.

CONCLUSIONS

Conclusively, both DMAB and ZOL are effective antiresorptive agents that improved BMD over 3 years in drug-naïve individuals. Moreover, DMAB might represent a more reliable initial option for patients with osteoporosis accompanied by low muscle mass.

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

RATIONALE

Osteoporosis is an abnormal reduction in bone mass and bone deterioration, leading to increased fracture risk. Alendronate belongs to the bisphosphonate class of drugs, which inhibit bone resorption by interfering with the activity of osteoclasts (bone cells that break down bone tissue). This is an update of a Cochrane review first published in 2008.

OBJECTIVES

To assess the benefits and harms of alendronate in the primary and secondary prevention of osteoporotic fractures in postmenopausal women at lower and higher risk of fracture, respectively.

SEARCH METHODS

We searched Evidence-Based Medicine Reviews (which includes CENTRAL), MEDLINE, Embase, two trial registers, drug approval agency websites, and the bibliographies of relevant systematic reviews to identify the studies included in this review. The latest search date was 01 February 2023. We imposed no restrictions on language, date, form of publication, or reported outcomes.

ELIGIBILITY CRITERIA

We included only randomized controlled trials that assessed the effects of alendronate on postmenopausal women. Targeted participants must have received at least one year of alendronate. We classified a study as secondary prevention if its population met one or more of the following hierarchical criteria: a diagnosis of osteoporosis, a history of vertebral fractures, a low bone mineral density T-score (-2.5 or lower), and 75 years old or older. If a study population met none of those criteria, we classified it as a primary prevention study.

OUTCOMES

Our major outcomes were clinical vertebral, non-vertebral, hip, and wrist fractures, withdrawals due to adverse events, and serious adverse events.

RISK OF BIAS

We used the Cochrane risk of bias 1 tool.

SYNTHESIS METHODS

We used standard methodological procedures expected by Cochrane. Based on the previous review experience, in which the clinical and methodological characteristics in the primary and secondary prevention studies were homogeneous, we used a fixed-effect model for meta-analysis and estimated effects using the risk ratio (RR) for dichotomous outcomes. Our base case analyses included all eligible placebo-controlled studies with usable data. We selected the data available for the longest treatment period. We consider a relative change exceeding 15% as clinically important.

INCLUDED STUDIES

We included 119 studies, of which 102 studies provided data for quantitative synthesis. Of these, we classified 34 studies (15,188 participants) as primary prevention and 68 studies (29,577 participants) as secondary prevention. We had concerns about risks of bias in most studies. Selection bias was the most frequently overlooked domain, with only 20 studies (19%) describing appropriate methods for both sequence generation and allocation concealment. Eight studies (8%) were at low risk of bias in all seven domains.

SYNTHESIS OF RESULTS

The base case analyses included 16 primary prevention studies (one to five years in length; 10,057 women) and 20 secondary prevention studies (one to three years in length; 7375 women) which compared alendronate 10 mg/day (or 70 mg/week) to placebo, no treatment, or both. Indirectness, imprecision, and risk of bias emerged as the main factors contributing to the downgrading of the certainty of the evidence. For primary prevention, alendronate may lead to a clinically important reduction in clinical vertebral fractures (16/1190 in the alendronate group versus 24/926 in the placebo group; RR 0.45, 95% confidence interval [CI] 0.25 to 0.84; absolute risk reduction [ARR] 1.4% fewer, 95% CI 1.9% fewer to 0.4% fewer; low-certainty evidence) and non-vertebral fractures (RR 0.83, 95% CI 0.72 to 0.97; ARR 1.6% fewer, 95% CI 2.6% fewer to 0.3% fewer; low-certainty evidence). However, clinically important differences were not observed for the following outcomes: hip fractures (RR 0.76, 95% CI 0.43 to 1.32; ARR 0.2% fewer, 95% CI 0.4% fewer to 0.2% more; low-certainty evidence); wrist fractures (RR 1.12, 95% CI 0.84 to 1.49; ARR 0.3% more, 95% CI 0.4% fewer to 1.1% more; low-certainty evidence); withdrawals due to adverse events (RR 1.03, 95% CI 0.89 to 1.18; ARR 0.2% more, 95% CI 0.9% fewer to 1.5% more; low-certainty evidence); and serious adverse events (RR 1.08, 95% CI 0.82 to 1.43; ARR 0.5% more, 95% CI 1.2% fewer to 2.8% more; low-certainty evidence). For secondary prevention, alendronate probably results in a clinically important reduction in clinical vertebral fractures (24/1114 in the alendronate group versus 51/1055 in the placebo group; RR 0.45, 95% CI 0.28 to 0.73; ARR 2.7% fewer, 95% CI 3.5% fewer to 1.3% fewer; moderate-certainty evidence). It may lead to a clinically important reduction in non-vertebral fractures (RR 0.80, 95% CI 0.64 to 0.99; ARR 2.8% fewer, 95% CI 5.1% fewer to 0.1% fewer; low-certainty evidence); hip fractures (RR 0.49, 95% CI 0.25 to 0.96; ARR 1.0% fewer, 95% CI 1.5% fewer to 0.1% fewer; low-certainty evidence); wrist fractures (RR 0.54, 95% CI 0.33 to 0.90; ARR 1.8% fewer, 95% CI 2.6% fewer to 0.4% fewer; low-certainty evidence); and serious adverse events (RR 0.75, 95% CI 0.59 to 0.96; ARR 3.5% fewer, 95% CI 5.8% fewer to 0.6% fewer; low-certainty evidence). However, the effects of alendronate for withdrawals due to adverse events are uncertain (RR 0.95, 95% CI 0.78 to 1.16; ARR 0.4% fewer, 95% CI 1.7% fewer to 1.3% more; very low-certainty evidence). Furthermore, the updated evidence for the safety risks of alendronate suggests that, irrespective of participants' risk of fracture, alendronate may lead to little or no difference for gastrointestinal adverse events. Zero incidents of osteonecrosis of the jaw and atypical femoral fracture were observed.

AUTHORS' CONCLUSIONS

For primary prevention, compared to placebo, alendronate 10 mg/day may reduce clinical vertebral and non-vertebral fractures, but it might make little or no difference to hip and wrist fractures, withdrawals due to adverse events, and serious adverse events. For secondary prevention, alendronate probably reduces clinical vertebral fractures, and may reduce non-vertebral, hip, and wrist fractures, and serious adverse events, compared to placebo. The evidence is very uncertain about the effect of alendronate on withdrawals due to adverse events.

FUNDING

This Cochrane review had no dedicated funding.

REGISTRATION

This review is an update of the previous review (DOI: 10.1002/14651858.CD001155).

Trends in Osteoporosis Drug Therapy Receipt Among Commercial and Medicare Advantage Enrollees in the United States, 2011-2022

CONTEXT

A national assessment of osteoporosis drug therapy (ODT) use can inform the extent of underdiagnosis and undertreatment of osteoporosis.

OBJECTIVE

The aim was to describe trends in ODT use by age, sex, fragility fracture, and documented osteoporosis.

METHODS

This was a retrospective analysis of patient-quarter observations for adults aged ≥50 years with commercial or Medicare Advantage health insurance in the OptumLabs Data Warehouse between 2011 and 2022. The primary outcome was the proportion of patient-quarter observations with ODT use stratified by age, sex, fragility fracture, and documented osteoporosis. Cuzick tests were performed to assess trends ODT use.

RESULTS

Analysis of 166 673 420 patient-quarter observations revealed that over 70% of patients with fragility fractures did not have documented osteoporosis. Among women aged ≥65 years with documented osteoporosis, ODT fill rates increased between 2011 and 2022 from 36.3% to 50.1% for women without fragility fractures (P < .001) and from 30.8% to 43.7% for women with fragility fractures (P < .001). However, ODT fill rates declined (9.2% to 7.4% between 2011 and 2022) for women with fragility fractures and no documented osteoporosis (P = .015). Similar trends were observed among women aged 50-64 years and men.

CONCLUSION

ODT use for patients with documented osteoporosis has increased but remains low. Low rates of ODT use for patients with fragility fractures in the absence of documented osteoporosis suggests that underdiagnosis of osteoporosis contributes to underuse of ODTs.

Role of Anabolic Anti-Osteoporosis Therapy in Diabetes Subjects

Diabetes mellitus (DM) is a metabolic disorder that leads to the destruction of various tissues including bones. The pathogenesis of osteoporosis (OP) varies in DM due to many specific factors. DM increases the risk of fracture as well as post-fracture mortality. It is because of this fact that OP treatment should not be neglected in patients with DM. OP therapy comprises anabolic as well as anti-resorptive agents. Primary OP as observed in post-menopausal women is associated with high bone turnover, whereas OP in DM is a disease of low bone turnover. Therefore, anabolic agents seem to be quite promising in cases of OP in DM. Although the anti-fracture efficacy of these drugs is proven beyond any doubt in the general population without DM, evidence in persons with DM is limited. Among the anabolic agents, teriparatide has the most evidence in favor of its efficacy and safety in persons with DM. Studies evaluating other anabolic agents such as abaloparatide and romosozumab in diabetic osteopathy are scarce in the literature. Future studies specifically in both type 1 and type 2 DM populations are needed to evaluate the effects of osteoanabolic agents.

Alendronate preserves bone mineral density in adults with sickle cell disease and osteoporosis

Low bone mineral density is highly prevalent in sickle cell disease (SCD); whether bisphosphonates can safely preserve or increase bone mass in SCD adults remains unknown. In this study, lumbar spine bone density remained stable with alendronate use, and treatment-related side effects were mostly mild and self-limited.

PURPOSE

To describe the effects of alendronate in adults with sickle cell disease (SCD) and osteoporosis.

METHODS

We reviewed retrospective clinical data from adults with SCD and osteoporosis treated with alendronate at a single center in Brazil (2009-2019). Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DXA) of the lumbar spine, femoral neck, and total hip. We analyzed BMD changes by alendronate treatment duration (months), stratified by sex, skeletal site, and SCD genotype.

RESULTS

Sixty-four SCD adults with osteoporosis (69% females, 73% HbSS, mean age ± standard deviation 42.4 ± 10.9 years) received alendronate for a median (interquartile range) of 48 (29, 73) months. Compared with males, females had significantly lower baseline BMD (g/cm2) at the femoral neck (0.72 vs 0.85, p =  < 0.001) and total hip (0.79 vs 0.88, p = 0.009). The between-sex differences in BMD changes were insignificant. Mean lumbar spine BMD significantly changed by 0.0357 g/cm2 (p = 0.028) in those on alendronate for > 5 years. Four adults (6.3%) reported mild therapy-related side effects. An atypical femoral diaphysis fracture, attributed to alendronate, was incidentally noted in a 37-year-old man on treatment for 4 years.

CONCLUSION

In this retrospective cohort of adults with SCD and osteoporosis on alendronate for a median of 48 months, we found no significant interactions between sex and changes in lumbar spine, femoral neck, or total hip BMD with alendronate. Lumbar spine BMD was stable in those on alendronate for < 5 years. Side effects of alendronate were mild, though one patient developed an atypical femoral fracture.

Clinical effects of teriparatide, abaloparatide, and romosozumab in postmenopausal osteoporosis

In the management of osteoporosis, anti-resorptive agents serve as a primary therapeutic approach. However, in cases where individuals exhibit an increased susceptibility to fractures, such as those characterized by severe low bone mass or a history of vertebral or hip fractures that markedly diminish life expectancy, the immediate reduction of fracture risk through the administration of osteoanabolic agents could be beneficial. Teriparatide, available in daily, once-weekly, or twice-weekly dosages, along with abaloparatide and romosozumab, constitutes a trio of such agents. Each of these medications is defined by unique characteristics, distinct efficacy profiles, and specific adverse effects. There is growing evidence to suggest that these agents have a superior effect on enhancing bone mineral density and reducing fracture incidence when compared to traditional bisphosphonate therapies. Nonetheless, their employment demands thorough consideration of clinical indications, which includes evaluating economic factors, the frequency of injections required, and the potential for adverse effects. The objective of this review is to consolidate the current evidence focusing primarily on the efficacy of these agents, with the goal of enhancing understanding and aiding in making more informed treatment decisions, particularly for those individuals who are at an elevated risk of fractures.

Isoginkgetin Inhibits RANKL-induced Osteoclastogenesis and Alleviates Bone Loss

Osteoporosis is characterized by excessive osteoclast activity leading to bone loss, decreased bone mineral density, and increased susceptibility to fractures. Through in vivo/vitro experiments, along with network pharmacology analysis, we aimed to explore the underlying mechanisms of Isoginkgetin (IGG) in inhibiting osteoclastogenesis, providing valuable insights for further research in the future. Firstly, we ascertained the safe concentration of IGG stimulation on BMMs, followed by a systematic exploration of the concentration gradient at which IGG inhibited osteoclastogenesis using TRAP analysis. An osteoporosis model was established to further validate the in vitro experimental findings by combining Micro-CT and immunohistochemical analysis. The results show that IGG did not exhibit cytotoxicity or proliferative effects on BMMs at concentrations equal to or less than 10 μM. Additionally, IGG inhibited the activity of osteoclastogenesis and bone resorption function at lower concentrations. RT-PCR and Western Blot results demonstrated that IGG could downregulate genes and proteins associated with osteoclastogenesis. The Western Blot results also showed that IGG inhibited the phosphorylation expression of P38, ERK, and P65 in the MAPK and NF-κB pathways. At the same time, it rescued the degradation of IκB-α at 15 and 60 min. IGG can also impact the relative expression levels of oxidative proteins such as SOD-1, HO-1, and catalase, thereby influencing cellular equilibrium and stress levels, ultimately inhibiting the formation of mature OC. In vivo experiments demonstrated that IGG alleviated bone loss caused by osteoclasts and improved relevant parameters of trabecular bone. So, IGG effectively attenuated osteoclastogenesis, and improved bone density, thereby portraying its role in osteoporosis management.

Unexpected Increase in Bone Mineral Density With Rapamycin and Low-Dose Naltrexone: A Case Report of a 52-Year-Old Woman With Osteopenia

Osteopenia and osteoporosis are prevalent bone disorders characterized by reduced bone mineral density (BMD), leading to an increased risk of fractures. This case report presents a 52-year-old Caucasian female patient with osteopenia who experienced an unexpected 15.9% increase in lumbar spine BMD within two years after enrolling in a clinical trial involving low-dose rapamycin and subsequently starting low-dose naltrexone. This case potentially opens novel treatment strategies for bone density improvement in aging populations.

Fracture prediction in rheumatoid arthritis: validation of FRAX with bone mineral density for incident major osteoporotic fractures

OBJECTIVES

FRAX uses clinical risk factors, with or without BMD, to calculate 10-year fracture risk. RA is a risk factor for osteoporotic fracture and a FRAX input variable. FRAX predates the current era of RA treatment. We examined how well FRAX predicts fracture in contemporary RA patients.

METHODS

Administrative data from patients receiving BMD testing were linked to the Manitoba Population Health Research Data Repository. Observed cumulative 10-year major osteoporotic fracture (MOF) probability was compared with FRAX-predicted 10-year MOF probability with BMD for assessing calibration. MOF risk stratification was assessed using Cox regression.

RESULTS

RA patients (n = 2099, 208 with incident MOF) and non-RA patients (n = 2099, with 165 incident MOF) were identified. For RA patients, FRAX-predicted 10-year risk was 13.2% and observed 10-year MOF risk was 13.2% (95% CI 11.6, 15.1). The slope of the calibration plot was 0.67 (95% CI 0.53, 0.81) in those with RA vs 0.98 (95% CI 0.61, 1.34) in non-RA patients. Risk was overestimated in RA patients with high FRAX scores (>20%), but FRAX was well calibrated in other groups. FRAX stratified risk in those with and without RA [hazard ratio (HR) 1.52 (95% CI 1.25, 1.72) vs 2.00 (95% CI 1.73, 2.31)], with slightly better performance in the latter (P for interaction = 0.004).

CONCLUSIONS

FRAX predicts fracture risk in contemporary RA patients but may slightly overestimate risk in those already at high predicted risk. Thus the current FRAX tool continues to be appropriate for fracture risk assessment in RA patients.

High bone fracture risk in a large modern cohort of liver transplant recipients

Liver transplantation (LT) has historically been associated with a high prevalence of osteoporosis, but most of the available data date back to late 1990s-early 2000s with limited sample size. Our aim was to assess the prevalence of bone fragility fractures and contributing factors in a large modern cohort of liver transplant recipients. Retrospective study of 429 consecutive patients receiving liver transplantation from 1/1/2010 to 31/12/2015. Final cohort included 366 patients. Electronic radiological images (lateral views of spine X-rays or Scout CT abdominal scans) performed within 6 months from LT, were blinded reviewed to screen for morphometric vertebral fractures. Symptomatic clinical fragility fractures were recorded from the medical records. Patients with fragility fractures in the cohort were 155/366 (42.3%), with no significant differences between sexes. Most sustained vertebral fractures (145/155, 93.5%), mild or moderate wedges, with severe fractures more frequently observed in women. Multiple vertebral fractures were common (41.3%). Fracture rates were similar across different etiologies of cirrhosis and independent of diabetes or glucocorticoids exposure. Kidney function was significantly worse in women with fractures. Independently of age, sex, alcohol use, eGFR, and etiology of liver disease, low BMI was significantly associated with an increased risk for fractures (adjusted OR 1.058, 95%CI 1.001-1.118, P = 0.046). Our study shows a considerable fracture burden in a large and modern cohort of liver transplant recipients. Given the very high prevalence of bone fractures, a metabolic bone disease screening should be implemented in patients awaiting liver transplantation.

Sequential therapy following teriparatide treatment in patients at high risk of osteoporotic patients

The use of medications in sequence is recommended in several osteoporosis guidelines to afford the best protection for the patient at very high risk of fracture. Sequential therapy following once-weekly as well as daily teriparatide treatment is a potent option for those patients.

High prevalence of low bone mineral density in middle-aged adults in Shanghai: a cross-sectional study

PURPOSE

To assess bone mineral density (BMD) in middle-aged individuals in Shanghai, in order to improve awareness of osteopenia and osteoporosis screening.

METHODS

The clinical data of 1107 permanent residents of Shanghai aged 40-60 years were collected using a random cluster sampling method. Osteoporosis questionnaire survey and BMD test were conducted. Mann-Whitney U and Chi-square test were used to compare sex, age and body mass index at different stages of bone mass, and Pearson test was used to conduct correlation analysis. Logistic regression was used to analyze the influencing factors.

RESULTS

The detection rates of osteopenia and osteoporosis were 59% and 12.5% respectively, and bone mineral density was correlated with sex, age, and body mass index (P < 0.05).

CONCLUSION

The incidence of low bone mass is high in the assessed population, screening for low bone mass should be actively carried out to improve public awareness. It is also good for public health management.

REGISTERED CLINICAL TRIAL

The trial was approved by Chinese Clinical Trial Registry on February 11, 2021(ChiCTR2100043369).

New Challenges: Use and Interpretation of Radius Bone Mineral Density

CONTEXT

It is unknown if isolated low bone mineral density (BMD) "osteoporosis" at the radius is associated with increased fracture risk, not only at the wrist but elsewhere, and whether it reflects more generalized skeletal fragility.

OBJECTIVE

This work aimed to review the association of radius BMD and fracture risk, the epidemiology of wrist fractures, isolated osteoporosis at the radius, and the concordance between radial BMD and femoral neck BMD.

METHODS

We completed a narrative literature review on radius BMD and fracture risk and current recommendations for measurement of radial BMD. We updated results of radial BMD and fracture results from the Study of Osteoporotic Fractures over 20 years and examined the concordance of BMD at the distal and proximal radius with femoral neck BMD T scores.

RESULTS

Radius BMD is a robust predictor of all types of fractures including hip and wrist but there is insufficient evidence to suggest that radius BMD predicts wrist fractures better than fractures at other sites. Fractures of the wrist tend to occur in younger, healthier women compared with hip and spine fractures. Nevertheless, wrist fractures are associated with an increased risk of future fractures and represent a missed opportunity for intervention. On a population level, the discordance between radius BMD and femoral neck BMD is small. But women with isolated osteoporosis at the radius had biochemical and microarchitecture deterioration that were similar to women with hip osteoporosis.

CONCLUSION

Future research should address the clinical implications of isolated osteoporosis at the radius and whether treatment is warranted.

Epimedium applied in the clinical treatment of osteoporosis patients with periodontitis

Osteoporosis and periodontitis, prevalent in middle-aged and elderly populations, share common features of bone loss and chronic inflammation. This study explores the hypothesis that Epimedium, known for its bone-strengthening properties, may enhance the effectiveness of conventional osteoporosis treatment in patients with coexisting periodontitis. This retrospective study analyzed clinical data from 120 patients with osteoporosis and periodontitis, divided into 2 groups. The control group received calcium carbonate, vitamin D, and zoledronic acid (CC + VD + ZA) therapy, while the observation group received additional Epimedium flavonoid treatment. Outcomes assessed included changes in bone mineral density (BMD), bone metabolism markers (β-CTx, N-MID, CT, ALP), periodontal indices (PD, AL, SBI, PLI), and inflammatory markers in gingival crevicular fluid (GCF) before and 6 months posttreatment. Compared to the control group, the observation group showed significantly greater increases in lumbar spine and proximal femur BMD and reductions in BM markers (P < .05). Periodontal health metrics (PD, AL, SBI, PLI) and GCF inflammatory markers (TNF-α, IL-1β, IL-6, IL-8, hs-CRP, ICAM-1, HMGB1, PGE2) were markedly improved in the observation group, correlating with enhanced total effective rates (TER) for osteoporosis (95.0%) and periodontitis (91.7%) and a reduced adverse event rate (AER). Epimedium shows promise as an adjunctive therapy in patients with osteoporosis and periodontitis, contributing to improved BMD, reduced inflammation, and enhanced periodontal health, suggesting its potential for broader clinical application in managing these coexisting conditions.

Pharmacological inhibition of HIF2 protects against bone loss in an experimental model of estrogen deficiency

Estrogen deficiency, which is linked to various pathological conditions such as primary ovarian insufficiency and postmenopausal osteoporosis, disrupts the delicate balance between bone formation and resorption. This imbalance leads to bone loss and an increased risk of fractures, primarily due to a significant reduction in trabecular bone mass. Trabecular osteoblasts, the cells responsible for bone formation within the trabecular compartment, originate from skeletal progenitors located in the bone marrow. The microenvironment of the bone marrow contains hypoxic (low oxygen) regions, and the hypoxia-inducible factor-2α (HIF2) plays a crucial role in cellular responses to these low-oxygen conditions. This study demonstrates that the loss of HIF2 in skeletal progenitors and their derivatives during development enhances trabecular bone mass by promoting bone formation. More importantly, PT2399, a small molecule that specifically inhibits HIF2, effectively prevents trabecular bone loss in ovariectomized adult mice, a model for estrogen-deficient bone loss. Both the genetic and pharmacological approaches result in an increase in osteoblast number, which is linked to the expansion of the pool of skeletal progenitor cells. This expansion either by loss or inhibition of HIF2 uncovers a pivotal mechanism for increasing osteoblast numbers and bone formation, resulting in greater trabecular bone mass.

Current and Developing Pharmacologic Agents for Improving Skeletal Health in Adults with Osteogenesis Imperfecta

Osteogenesis imperfecta (OI) is a genetic disorder characterized by increased bone fragility largely caused by defects in structure, synthesis, or post-translational processing of type I collagen. Drugs currently used to improve skeletal health in OI were initially developed to treat osteoporosis and clinical trials are ongoing to study their effectiveness in OI adults. Additionally, novel bone-protective agents are in preclinical studies and various phases of OI clinical trials. This review summarizes current knowledge on available pharmacologic agents and current drug trials involving OI participants. A PubMed online database search of all study types published in the English language using the terms "osteogenesis imperfecta," "OI," and "brittle bone disease" was performed in August 2022. Articles screened were restricted to adults. A ClinicalTrials.gov database search of all studies involving "osteogenesis imperfecta" was performed in August 2023. Although clinical trial data are limited, bisphosphonates and teriparatide may be useful in improving bone mineral density. As of yet, no clinical trials are available that adequately evaluate the usefulness of current therapies in reducing fracture risk. Several therapeutics, including teriparatide, setrusumab, anti-TGF-β antibodies, and allogeneic stem cells, are being studied in clinical trials. Preclinical studies involving Dickkopf-1 antagonists present promising data in non-OI bone disease, and could be useful in OI. Research is ongoing to improve therapeutic options for adults with OI and clinical trials involving gene-editing may be possible in the coming decade.

Association of Delayed Denosumab Dosing with Increased Risk of Fractures: A Population-Based Retrospective Study

BACKGRUOUND

Inhibitory effects of denosumab on bone remodeling are reversible and disappear once treatment is discontinued. Herein, we examined whether and to what extent delayed denosumab administration is also associated with fracture risk using nation-wide data.

METHODS

The study cohort included women aged 45 to 89 years who were started on denosumab for osteoporosis between October 2017 and December 2019 using data from the Korean Health Insurance Review and Assessment service. Participants were stratified according to the time of their subsequent denosumab administration from the last denosumab administration, including those with within 30 days early dosing (ED30), within the planned time of 180-210 days (referent), within 30-90 days of delayed dosing (DD90), within 90-180 days of delayed dosing (DD180), and longer than 181 days of delayed dosing (DD181+). The primary outcome was the incidence of all clinical fractures.

RESULTS

A total of 149,199 participants included and 2,323 all clinical fractures (including 1,223 vertebral fractures) occurred. The incidence of all fractures was significantly higher in the DD90 compared to reference group (hazard ratio [HR], 1.2; 95% confidence interval [CI], 1.1 to 1.4). The risk of all fracture was even higher in the longer delayed DD180 group (HR, 1.9; 95% CI, 1.6 to 2.3) and DD181+ group (HR, 1.8; 95% CI, 1.5 to 2.2). Increased risks of fractures with delayed dosing were consistently observed for vertebral fractures.

CONCLUSION

Delayed denosumab dosing, even by 1 to 3 months, was significantly associated with increased fracture risk. Maintaining the correct dosing schedule should be emphasized when starting denosumab.

A Retrospective Audit of Osteoporosis Management Following Fragility Fractures in a Hospital Setting

Background Fragility fractures, often caused by osteoporosis, are a major public health concern among the growing population of the United Kingdom (UK). In addition to being a major source of illness and mortality, the rising incidence of osteoporosis places a heavy strain on healthcare systems if it is not adequately managed. In order to lower the risk of additional fractures, current guidelines place a strong emphasis on the timely evaluation and treatment of fragility fractures. Methods This retrospective audit was carried out in Warrington Hospital, UK, to examine the management of fragility fractures in patients aged 65 years and above across two cycles (January to March 2022 and April to May 2023, respectively). All data was obtained from electronic medical records, and management was assessed, including treatment with bisphosphonates, vitamin D, dual-energy X-ray absorptiometry (DEXA) scans and further referrals for metabolic bone clinics. Results The first cycle included 144 inpatients and showed significant under-utilization with only 16% receiving bisphosphonates treatment (23 inpatient prescriptions), low referrals for DEXA scan and metabolic bone clinics. Assessment and supplementation of vitamin D was also suboptimal. The second cycle of the audit reviewed 165 patients and showed minor improvement in bisphosphonates prescription, although post-discharge rates were low with around 80% of patients (104 of 131, as 34 patients were prescribed while inpatient) not receiving medications. The DEXA scans and metabolic bone clinic referrals also remained inadequate in the second cycle. Conclusions This audit highlighted the significant gap in the management of fragility fractures and persistent deficiencies in spite of robust guidelines and interventions set by various bodies. The implementation of treatment guidelines for osteoporotic patients at hospital level can help in timely initiation of antiresorptive therapy, DEXA scans and utilisation of metabolic bone clinics to optimise outcomes and reduce the burden on healthcare systems. There is a need for further research and education to improve this adherence to set guidelines and improve outcomes.

The Portuguese state of the art on osteoporosis and fracture risk: an update on the treatment options

Osteoporosis and fragility fractures are serious public health problems, which greatly impact individual health and the economy of other health services. Pharmacological treatment is still one of the main elements of clinical intervention, combined with non-pharmacological measures, in preventing the occurrence of fragility fractures. The emergence of promising new pharmacological options in the treatment of osteoporosis seems to renew expectations in the prevention of complications and a subsequent reduction in morbidity and mortality, including symptomatic treatment, improved physical function and a better quality of life. This review aims to provide updated information on the pharmacological treatment of osteoporosis in the adult population. A comprehensive PubMed search was performed to review the current evidence on osteoporosis treatment. Of the 378 articles identified from the initial queries, the final review included 80 articles. Currently, the following pharmacological options are available: antiresorptive (bisphosphonates, denosumab, postmenopausal hormone replacement therapy and selective oestrogen receptor modulators), bone-forming agents (essentially, teriparatide and abaloparatide) and the new dual-action therapy (romosozumab), recently approved by the US Food and Drug Administration and the European Medicines Agency, but which is not yet an option in Portugal. Therapeutic selection is essentially based on assessment of cost-effectiveness, since current evidence does not suggest any differences between the distinctive classes in reducing the risk of fractures, but this analysis is limited by the scarcity of comparative intraclass studies. Notwithstanding, romosozumab, as a dual effect therapy, is promising in resolving the physiological limitations resulting from the merely unilateral action of antiresorptive agents and bone-forming agents in the inseparable relationship between bone formation and resorption. However, its cardiovascular safety raises some concerns, and this topic is still being debated. The underdiagnosis and the undertreatment of osteoporosis remain one of the greatest challenges of the 21st century. Over the years, new drugs have appeared that have tried to address these problems with a direct impact on the health of populations, but a long way remains to be come in optimising their effectiveness, safety and tolerability.

Optimal Management of Osteoporosis in the Spinal Cord (Injury) Population

Spinal cord injury (SCI) leads to significant bone loss resulting in osteoporosis and an increased risk of fractures below the level of injury. It is imperative to screen for osteoporosis in all individuals with SCI starting immediately after the acute injury. Although data are limited, clinicians are encouraged to discuss preventative treatment in the acute SCI period and to treat osteoporosis when diagnosed.

Diagnosis and Management of Atypical Femoral Fractures and Medication-Related Osteonecrosis of the Jaw in Patients with Osteoporosis

Anti-osteoporosis treatments reduce fracture risk but maybe associated with rare adverse events with long-term use such as atypical femoral fractures (AFFs) and medication-related osteonecrosis of the jaw (MRONJ). AFFs are rare but more likely with prolonged bisphosphonate use, whereas MRONJ incidence is higher in cancer patients on high-dose antiresorptive therapy. Following diagnosis, effective treatment options are available to manage both of these rare complications. An individualized treatment approach is advised with close monitoring.

Modern approach to bone comorbidity in prolactinoma

Prolactinomas account for more than half of pituitary adenomas, and besides their clinical impact on fertility and gonadal function, they lead to detrimental effects on bone. Patients with prolactinoma are prone to deterioration of bone structure caused not only by prolactin (PRL) induced hypogonadism but also by its direct actions on bone cells and calcium metabolism. However, clinical studies have shown inconsistent evidence regarding whether PRL could have a deleterious effect independently from gonadal insufficiency on skeletal integrity. Seminal studies from our group reported an increased prevalence of vertebral fractures (VFs) in both female and male patients with prolactinoma. Treatment of prolactinoma with dopamine agonists can restore gonadal function and improve bone mineral density. Since the presence of VFs may be related to more aggressive disease, bone comorbidities in prolactinoma should be managed by a multidisciplinary team in line with the recent concept of 'pituitary tumors centers of excellence'. The review aims to evaluate the mechanism of PRL actions on bone, as well as to provide practical indications for a modern approach to the management of skeletal complications of patients with prolactin-secreting adenoma considering different clinical characteristics and outcomes.