Comparing therapies for postmenopausal osteoporosis prevention and treatment

Examining the Effect of Medication Adherence on Risk of Subsequent Fracture Among Women with a Fragility Fracture in the U.S. Medicare Population

BACKGROUND

In the United States, osteoporosis affects approximately 10 million people, of whom 80% are women, and it contributes a significant clinical burden to the community. Poor adherence to osteoporosis medications adds to the overall burden of illness.

OBJECTIVE

To examine the association of osteoporosis medication adherence and the risk of a subsequent fracture among Medicare-enrolled women with a previous fragility fracture.

METHODS

This study was a retrospective observational analysis of U.S. administrative claims data among female Medicare beneficiaries who had a nontrauma closed fragility fracture between January 1, 2011, and December 31, 2011. Patients were required to have continuous medical and pharmacy enrollment 12 months pre- and postfracture date. In addition, patients were required to have an osteoporosis medication prescription for a bisphosphonate (alendronate, risedronate, pamidronate, etidronate, zoledronate, and tiludronate), calcitonin, denosumab, raloxifene, or teriparatide during the follow-up period. Adherence was calculated using cumulative medication possession ratio (MPR) from the treatment initiation date in 30-day increments. MPR was stratified into high adherence (MPR ≥ 80%), moderate adherence (50% ≤ MPR > 80%), and low adherence (MPR < 50%). Outcomes included first subsequent fracture after treatment initiation; patients were censored at treatment discontinuation, or end of the 12-month period posttreatment initiation. Covariates included demographics, comorbidities, osteoporosis medications, medications associated with falls, and health care utilization. Cox regression was used to model subsequent fractures with time-dependent cumulative MPR.

RESULTS

Of the 1,292,248 Medicare enrollees who had a fracture in 2011, a total of 103,852 (8.0%) women aged ≥ 65 years with a fragility fracture were identified. Overall, 27,736 (26.7%) patients were treated with osteoporosis medication within 12 months of the fragility fracture (mean time to treatment initiation was 85.0 ± 84.6 days). Over half of the patients were highly adherent (MPR ≥ 80%) to osteoporosis medications during the follow-up (n = 14,112; 50.9%). Almost a third of the patients had low adherence (MPR < 50%; n = 9,022, 32.5%), followed by patients with moderate adherence (50% ≤ MPR > 80%; n = 4,602, 16.6%). After adjusting for demographics and clinical characteristics, patients with low and moderate adherence to osteoporosis medications were 33% (hazard ratio [HR] = 1.33; 95% CI = 1.17-1.50, P < 0.001) and 19% (HR = 1.19; 95% CI = 1.02-1.38, P = 0.026) more likely to have a subsequent fracture, respectively, compared with patients with high adherence. Low adherence patients had a 32% and 34% increased risk for a hip/pelvis/femur fracture (HR = 1.32; 95% CI = 1.09-1.59, P = 0.005) and a clinical vertebral fracture (HR = 1.34; 95% CI = 1.09-1.63, P = 0.005), respectively, compared with high adherence patients.

CONCLUSIONS

Medicare-enrolled women with low and moderate adherence to osteoporosis medications had a higher risk of a subsequent fracture compared with high adherence patients. These results highlight the importance of improving osteoporosis medication adherence among women enrolled in Medicare.

DISCLOSURES

This study was funded by Eli Lilly. Xie, Keshishian, and Baser are employees of STATinMED Research, a paid consultant to Eli Lilly in connection with the study design, data analysis, and development of the manuscript for this study. Boytsov, Burge, Lombard, and Zhang are employees and stock owners of Eli Lilly. At the time of research, Krohn was an employee of Eli Lilly. Study concept and design were contributed by Burge and Lombard, along with the other authors. Xie, Baser, and Keshishian took the lead in data collection, assisted by the other authors. Data interpretation was performed by Krohn and Zhang, with assistance from the other authors. The manuscript was written by Keshishian and Boytsov, along with the other authors, and revised by Boytsov, Keshishian, and Burge, along with the other authors.

Examining the treatment gap and risk of subsequent fractures among females with a fragility fracture in the US Medicare population

Our aim was to evaluate the gap in osteoporosis treatment and the impact of osteoporosis treatment on subsequent fragility fractures. We found osteoporosis medication use lowered risk of subsequent fractures by 21% and that black race, higher CCI scores, dementia, and kidney diseases reduced the likelihood of osteoporosis medication use.

INTRODUCTION

The goal of this study was to evaluate the predictors of osteoporosis medication use and compare the risk of fragility fractures within 1 year of a fragility fracture between osteoporosis treated and untreated women.

METHODS

We conducted a retrospective, observational cohort study using the national Medicare database. Elderly women (≥65 years) who were hospitalized or had an outpatient/ER service for fragility fracture between January 1, 2011 and December 31, 2011 were included. The outcomes of interest were the correlates of and time-to-osteoporosis medication use and risk of a subsequent fracture within 12 months for treated and untreated women. Cox regression was used to evaluate the predictors of treatment use and the risk of fracture based on treatment status.

RESULTS

Women (28,722) (27.7%) were treated with osteoporosis medication within 12 months of index fracture, and 74,979 (72.2%) were untreated. A number of patient characteristics were associated with a reduced likelihood of osteoporosis medication use, including black race, higher Charlson comorbidity index scores, presence of dementia, and kidney diseases in the baseline. The predictor most strongly and positively associated with osteoporosis medication use after fracture was osteoporosis medication use before fragility fracture (HR = 7.87; 95% CI 7.67-8.07). After adjusting for baseline characteristics, osteoporosis medication use lowered the risk of subsequent fractures by 21% (HR = 0.79, 95% CI 0.75-0.83) over 12 months compared to women without treatment.

CONCLUSIONS

Demographics and clinical characteristics were strong predictors of osteoporosis medication use. In the US Medicare population, osteoporosis treatment significantly reduced the risk of fragility fractures.

Effect of Traditional Chinese Medicine Product, QiangGuYin, on Bone Mineral Density and Bone Turnover in Chinese Postmenopausal Osteoporosis

Introduction. The aim of this study was to investigate the efficacy of herbal formula QiangGuYin (QGY) in postmenopausal women. Materials and Methods. A total of 240 participants from six clinical centers were randomly to receive alendronate 70 mg/week, QGY granules 20 g/day, and placebo. Primary end points were BMD changes over 6 and 12 months; secondary end points were bone turnover markers changes at 3, 6, 9, and 12 months. Safety was monitored by clinical adverse events reported during the follow-up. Results. Of 240 women recruited, 218 completed the study. Significant BMD increases from baseline were observed over 6 and 12 months at each observed part both in QGY and alendronate compared with placebo (p < 0.01). Alendronate-treated subjects had significant decreases in β-CTX compared to QGY-treated subjects at each time point assessed (p < 0.01). Reduction in t-P1NP was only observed in the QGY group at 3 and 6 months (-23.81% and -3.07%, resp.). No significant difference was observed in the overall incidence of clinical adverse events among the alendronate group and the QGY group (5.0% versus 7.5%, p = 0.513). Conclusion. 1-Year treatment with QGY demonstrated a safe statistical increase in BMD and new balance may be rebuilt after 9 months. This trail is registered with ChiCTR-POC-16008026.

Adherence to osteoporosis regimens among men and analysis of risk factors of poor compliance: a 2-year analytical review

BACKGROUND

To investigate adherence and patient-specific factors associated with poor compliance with osteoporosis regimens among men.

METHODS

In this retrospective chart review study, we collected data on male patients with osteoporosis treated in accordance with therapeutic recommendations. Adherence was determined by the compliance and persistence of those patients who had been dispensed an osteoporosis regimen after an index prescription. All osteoporosis regimens were considered equivalent for the purpose of investigating adherence.

RESULTS

The prescriptions of 333 males met the inclusion criteria for data collection. The mean age was 68.6 ± 10.4 years. The median medication possession ratio (MPR, %) at years 1 and 2 was 90.1% (interquartile range (IQR) 19-100) and 53.7% (IQR 10.4-100), respectively; 52.3% of male patients at year 1 and 37.5% at year 2 had good compliance (defined as a MPR≧80%). The 1- and 2-year persistence rates were 45.9% and 30.0%, respectively. Patient-specific factors associated with poor compliance (MPR < 80%) during year 1 were first prescriptions given by orthopedists (odds ratio (OR) = 2.67; 95% confidence interval (CI) = 1.58-4.53; adjusted OR = 2.30, 95% CI = 1.26-4.22, p = 0.007). Male patients with rheumatoid arthritis (RA) (OR = 0.22, 95% CI = 0.06-0.78, adjusted OR = 0.19, 95% CI = 0.04-0.81, p = 0.025) and baseline bone mineral density (BMD) measurements (OR = 0.52, 95% CI = 0.32-0.85; adjusted OR = 0.51; 95% CI = 0.28-0.93, p = 0.029) were less likely to have poor compliance.

CONCLUSIONS

Adherence to osteoporosis regimens in males was suboptimal in our study. Poor compliance was more likely in prescription of the first anti-osteoporotic regimen by an orthopedist. Men with RA and BMD measurements before therapy had a lower risk of non-adherence. Healthcare professionals need to target patients with specific factors to improve adherence to osteoporotic regimens.

Lasofoxifene: selective estrogen receptor modulator for the prevention and treatment of postmenopausal osteoporosis

OBJECTIVE

To review literature evaluating the pharmacology, pharmacokinetics, clinical efficacy, and adverse effects of lasofoxifene (CP-336156), a selective estrogen receptor modulator (SERM) that is not approved for use in the US.

DATA SOURCES

Literature was accessed through the MEDLINE and EMBASE databases (1985-June 2010) using the terms lasofoxifene and selective estrogen receptor modulators. Reference lists from retrieved articles were also manually reviewed. The Food and Drug Administration and Pfizer provided additional information.

STUDY SELECTION AND DATA EXTRACTION

All clinical trials evaluating lasofoxifene were included in this review. In addition, all articles evaluating the pharmacology, pharmacokinetics, and safety of lasofoxifene in humans were reviewed.

DATA SYNTHESIS

Lasofoxifene is a third-generation SERM with markedly higher in vitro and in vivo potency and oral bioavailability than other SERMs. The drug has produced significant improvements in bone density and biochemical markers of bone turnover in preclinical studies and in Phase 2 and 3 clinical trials. In these trials, lasofoxifene has shown a favorable safety profile, with adverse events including hot flushes, leg cramps, and increased vaginal moisture. One 2-year major comparative study in postmenopausal women determined that lasofoxifene and raloxifene were equally effective at increasing total hip bone mineral density (BMD), while lasofoxifene had a significantly greater effect on lumbar spine BMD.

CONCLUSIONS

Osteoporosis is a significant health problem. While the results of further clinical trials are needed to define the risks and benefits of treatment, particularly relating to fractures, lasofoxifene may prove to be an effective and well-tolerated therapeutic option for the prevention of bone loss in postmenopausal women.

[High morbid-mortability and reduced level of osteoporosis diagnosis among elderly people who had hip fractures in São Paulo City]

OBJECTIVE

To know the morbid-mortality following an osteoporotic hip fracture in elderly patients living in São Paulo.

PATIENTS AND METHODS

This study evaluated prospectively all patient over 60 years admitted in 2 school-hospitals in the city of São Paulo in a following 6-month period due to a osteoporotic proximal femur fracture. All of them filled up the Health Assessment Questionnaire (HAQ) and had their chart reviewed. After 6 months they were re-interviewed. Linear regression analysis was utilized to determine the factors related to functional ability.

RESULTS

56 patients were included (mean age 80.7 +/- 7.9 years old, 80.4% females). After the 6-month follow up the mortality rate was 23.2%. Only 30% of the patients returned to their previous activities, and 11.6% became totally dependent. Factors related to worse functional ability after fracture were HAQ before fracture, institutionalization after fracture and age (r(2) 0.482). The diagnosis of osteoporosis was informed only by 13.9% of them, and just 11.6% received any treatment for that.

CONCLUSION

Our results showed the great impact of these fractures on mortality and in the functional ability of these patients. Nevertheless, many of our physicians do not inform the patients about the diagnosis of osteoporosis and, consequently, the treatment of this condition is jeopardized.

Valid treatment options for osteoporosis and osteopenia in HIV-infected persons

OBJECTIVE

To review clinical data on bone ossification agents that may be considered for use in the treatment of osteoporosis and osteopenia in HIV-infected patients.

DATA SOURCES

A literature search was performed using MEDLINE (1950-January 2008), EMBASE, PubMed, and abstracts from major HIV conferences (February 2001-October 2007). These searches were limited to human data published in English and used the key words bisphosphonates, calcitonin, raloxifene, teriparatide, HAART, osteopenia, osteoporosis, and HIV/AIDS. Additional articles were retrieved from citations of selected references.

STUDY SELECTION AND DATA EXTRACTION

Relevant information on the pharmacology, pharmacokinetics, safety, and efficacy of available treatment with hormonal and nonhormonal agents was selected. Greater emphasis was placed on randomized clinical trials than on retrospective studies.

DATA SYNTHESIS

Osteoporosis in HIV-infected persons is at least as prevalent as in postmenopausal women, yet this population is not listed in primary care guidelines as one that should be considered for screening. In addition to bisphosphonates, calcitonin, raloxifene, and teriparatide are used to treat bone disorders. Three clinical trials to date have evaluated the use of a bisphosphonate in HIV-infected persons. The trials showed a marked increase in bone mineral density in patients taking alendronate versus those in the control groups (with/without calcium, exercise, and/or vitamin D in 1 or both arms). Dosing restrictions complicate the use of these agents; diet, exercise, and calcium supplementation remain the foremost recommended strategies to prevent bone loss. The use of estrogen, testosterone, calcitonin, and teriparatide is less studied in HIV-positive patients, but may be considered in select cases. There are some investigational drugs and agents not available in the US; however, there are not enough data to support their use.

CONCLUSIONS

Alendronate appears to be a promising treatment option for HIV-infected patients with osteoporosis and osteopenia. Further research is required to determine the safety and efficacy of other available drugs. Until additional information is provided, and with available knowledge on the metabolism profiles of antiretroviral and bone ossification agents, alendronate appears to be the preferred agent to use in this population.

AA, Acúrcio FDA. Treatment of postmenopausal osteoporosis in women: a systematic review

Osteoporosis, a typical disease of the elderly, has become a frequent and relevant public health problem. Several drugs are available for treatment of osteoporosis, some of which are currently dispensed by the Brazilian Unified National Health System. The objective of this study was to present a systematic review of drugs for treatment of osteoporosis, focusing on the adequacy of clinical protocols based on existing evidence in the scientific literature. We conducted a search for randomized clinical trials in PubMed and LILACS that presented results for bone mineral density, incidence of vertebral fractures, and adverse effects. 32 articles met the review's inclusion criteria. Bisphosphonates were reported to have consistently reduced the risk of vertebral fractures. Hormone replacement therapy showed positive outcomes, but its use has been found to increase the risk of cardiovascular disease and breast cancer. Teriparatide and monofluorophosphate also showed efficacy against osteoporosis. Calcium and vitamin D were given to patients as food supplements.

Changes in micro-CT 3D bone parameters reflect effects of a potent cathepsin K inhibitor (SB-553484) on bone resorption and cortical bone formation in ovariectomized mice

Cathepsin K is a cysteine proteinase that is highly expressed by osteoclasts and is being pursued as a potential drug target for the treatment of osteoporosis. We have reported that microcomputed tomography (micro-CT) analysis of bone microarchitecture may serve as a valuable tool for evaluating both antiresorptive and anabolic agents in ovariectomized (OVX) mice. The purpose of this study was to evaluate the effect of SB-553484, a novel cathepsin K inhibitor (human Ki,app=0.14 nM, mouse Ki,app=26 nM), on the OVX mice by micro-CT bone morphometric analysis. Seven weeks female BALB/c mice were OVX or sham-operated. OVX animals were treated with SB-553484 (30 mg/kg, sc) or Rolipram (10 mg/kg, po), a phosphodiesterase 4 inhibitor used as a positive bone anabolic agent, twice a day for 2 weeks. Both SB-553484 and Rolipram significantly prevented the decrease of trabecular bone volume as well as the deterioration of trabecular architecture in OVX mice. Interestingly, SB-553484 demonstrated a more pronounced effect in improvement of trabecular separation, number and connectivity, and a weaker effect in improvement of trabecular thickness compared to that of Rolipram. These differences indicate that SB-553484 mainly acted as an antiresorptive agent in OVX-induced loss of trabecular bone. On the other hand, SB-553484 significantly increased cortical bone volume and cortical thickness as well as Rolipram in OVX mice indicating an unexpected stimulatory effect of SB-553484 on cortical bone formation. These data suggest that targeting cathepsin K may prove therapeutically beneficial in the treatment of diseases with accelerated bone loss such as postmenopausal osteoporosis not only by inhibiting bone resorption but also by potentially stimulating cortical bone formation.

Compliance with osteoporosis drug therapy and risk of fracture

INTRODUCTION

Patient compliance with osteoporosis drug therapy is often poor in clinical practice and may be associated with higher risk of fracture.

METHODS

A nested case-control study was undertaken using a US health insurance claims database. The source population included all women aged >or=45 years who began drug therapy for osteoporosis. Cases consisted of those who experienced an osteoporosis-related fracture; they were matched to controls without osteoporosis-related fracture. Compliance with osteoporosis drug treatment was assessed in terms of the number of therapy-days received and medication possession ratio (MPR). Conditional logistic regression was employed to examine the relationship between compliance and fracture risk.

RESULTS

A total of 453 women with osteoporosis-related fracture were identified and matched to 2,160 controls. Fracture risk was significantly lower for patients with >180 days of therapy [181-360 days: odds ratio (OR) = 0.70, 95% CI = 0.49-0.99; >360 days: OR = 0.65, 95% CI = 0.43-0.99) versus those with <or=30 days. Risk was also lower for patients with MPR >or=90% (OR = 0.70, 95% CI = 0.52-0.93) versus those with MPR <30%. Fracture risk decreased as compliance increased (p(trend) < 0.05).

CONCLUSION

Among women initiating drug therapy for osteoporosis, better compliance is associated with reduced risk of fracture.

Analysis of Change Patterns of Microcomputed Tomography 3-Dimensional Bone Parameters as a High-Throughput Tool to Evaluate Antiosteoporotic Effects of Agents at an Early Stage of Ovariectomy-Induced Osteoporosis in Mice

OBJECTIVES

The purposes of this study were to develop an osteoporosis model in a short period of 2 weeks after ovariectomy in mice and to investigate whether analysis of microcomputed tomography (muCT) 3-dimensional bone parameters could provide useful information on the mechanism of action of antiosteoporotic agents.

MATERIALS AND METHODS

Mice were ovariectomized (OVX) or sham-operated, and the OVX mice were treated daily with 17beta-estradiol (E2), parathyroid hormone (PTH[1-34]), raloxifene, rolipram, or vehicle for 2 weeks. On day 14 post-OVX, the left femur bones were removed and then the distal metaphyseal bone was analyzed by both muCT and histomorphometry.

RESULTS

The trabecular bone volume, thickness, number, and connectivity significantly decreased and the number of osteoclasts increased in OVX mice. Treatment of OVX animals with each of the 4 antiosteoporotic agents significantly increased the bone volume and improved the bone architecture. However, the improvement of trabecular thickness in the rolipram-treated group and that of cortical thickness in the PTH(1-34)-treated group were the most marked, whereas the improvement of connectivity in the rolipram-treated group was the least among the drug-treated groups. These different improving effects of agents on the bone parameters reflect the differential effects of these agents on bone formation and bone resorption.

CONCLUSIONS

This study demonstrated the feasibility of evaluating the effect of the antiosteoporotic agents within 2 weeks after ovariectomy in mice. The muCT analysis may serve as a valuable tool, specifically in a high-throughput pharmacological screening test, offering useful information regarding the effects of test compounds on both bone resorption and formation.

Calorie intake misreporting by diet record and food frequency questionnaire compared to doubly labeled water among postmenopausal women

OBJECTIVE

We assessed the extent of energy misreporting from the use of a self-administered 7-day diet record (7-DDR) and a widely used food frequency questionnaire (FFQ) compared to total energy expenditure from doubly labeled water (DLW) in a group of postmenopausal women.

DESIGN

At baseline, 65 healthy postmenopausal women were instructed to fill out the National Cancer Institute's (NCI) FFQ and a 7-DDR. Average total energy expenditure using the DLW method was also performed at baseline.

RESULTS

On average, the women underestimated total energy intake compared to total energy expenditure assessed from DLW by 37% on the 7-DDR and 42% on the FFQ.

CONCLUSIONS

These findings suggest that the interpretation of findings from the 7-DDR- and FFQ-based energy-disease association studies in postmenopausal women needs further evaluation.

SPONSORSHIP

This research was supported (in part) by the Intramural Program of the NIH (National Cancer Institute).

Compliance with drug therapy for postmenopausal osteoporosis

INTRODUCTION

Patient compliance with pharmacotherapy for osteoporosis is typically poor in clinical practice; less frequent dosing with bisphosphonates may improve compliance.

METHODS

Using data from 49 US health plans, we identified all women aged >/=45 years with osteoporosis who initiated therapy with a bisphosphonate, calcitonin, estrogen, or raloxifene. Compliance was examined alternatively in terms of incidence of adherence failure (medication days <80% of possible) and persistence failure (gap in therapy >/=90 days), and was compared across treatment groups using Kaplan-Meier methods and Cox proportional hazards models.

RESULTS

The study population included 18,822 women, 48% of whom initiated weekly bisphosphonate therapy. Overall risk of adherence failure was 47% at 3 months, 70% at 1 year, and 84% at 3 years. Risk of persistence failure was 47% at 1 year, and 77% at 3 years. In multivariate analyses, risk of adherence failure was higher for calcitonin (hazard ratio=2.7 vs weekly bisphosphonate therapy, p<0.01), but comparable for all other therapies. Relative risks of persistence failure were generally similar.

CONCLUSIONS

Approximately three-quarters of women who initiate osteoporosis drug therapy are non-adherent with treatment within 12 months, and almost 50% have discontinued such therapy by this time. Compliance with weekly bisphosphonate therapy is generally no better than that with osteoporosis medications requiring more frequent dosing.

The relationship between blood leptin level and bone density is specific to ethnicity and menopausal status

Leptin, the obesity hormone, has been linked to bone mineralization and tumorigenesis. In addition, both bone mineral density (BMD) and postmenopausal breast cancer are associated with obesity, but the interrelationships between obesity, leptin, BMD, and breast cancer are not yet clear. In particular, there is little published research comparing white and black women in terms of these variables. We obtained blood specimens for leptin analysis from a group of 320 breast cancer patients and controls with an ethnic composition of 49% white women and 51% black women. Distal and proximal radial BMD (DBMD and PBMD) were measured by dual-energy X-ray absorptiometry, and age- and ethnicity-specific standardized scores (Z-scores) were calculated for bone density. Blood leptin levels were determined by radioimmunoassay. Blood leptin level was not linked to breast cancer risk. Leptin levels were significantly higher in black women than in white women and were also significantly higher in obese and overweight women than in normal-weight women. Black women weighed more and had a higher body mass index (BMI) than white women. After controlling for BMI, leptin was correlated with DBMD ( r = .17; P < .05) and PBMD ( r = .21; P < .05) in whites, but not in blacks. Leptin was also correlated with both distal and proximal Z-scores in postmenopausal women ( r = .14 and .13; P < .05). Thus leptin may be a predictor for BMD in a population that is prone to have a low BMD, and this relationship is independent of the effect of body weight on leptin levels. Our results suggest that ethnicity and menopausal status should be considered when comparing results from different studies.

Phytoestrogens derived from red clover: an alternative to estrogen replacement therapy?

The benefits of plant extracts from soy and red clover as alternatives to conventional hormone replacement therapy (HRT) have been debated in the past. Here, an attempt has been made to summarize the biochemical and pharmacological data in the light of clinical aspects. Red clover and soy extracts contain isoflavones, which have a high affinity to estrogen receptor alpha (ERalpha), estrogen receptor beta (ERbeta), progesterone receptor (PR) and androgen receptor (AR). The higher affinity to ERbeta compared to ERalpha has been used as an explanation why red clover extracts function as food additives to treat menopausal disorders and may reduce risk of breast cancer. Biochemical analysis shows that these representatives of phytoestrogens have multiple actions beside selective estrogen receptor modulator (SERM)-activity. They act as selective estrogen enzyme modulators (SEEMs), have antioxidant activity and interact with transcription factors such as NF-kappaB. Furthermore, it is indicated that they have protective effects on osteoporosis and the cardiovascular system. Currently 40-50mg of isoflavones (biochanin A, daidzein, formononetin and genistein) are recommended as daily dose. This recommendation is based on the daily intake of phytoestrogens in a traditional Japanese diet.

Treatment of Postmenopausal Osteoporosis

Osteoporosis is a major public health burden. The most devastating outcome of osteoporosis is fracture, which results in increased morbidity and mortality. These fractures most often occur in the vertebrae and indicate an increased risk of future vertebral and hip fractures. Consequently, it is important to identify patients at risk for fracture and to intervene with pharmacologic therapies, lifestyle changes, or both to reduce the frequency of the first or subsequent fracture. Moreover, because osteoporosis is a chronic condition requiring long-term therapy, factors that increase compliance and improve safety and efficacy outcomes should be considered when treatment is selected. The bisphosphonates alendronate and risedronate can substantially reduce the risk of both hip and vertebral fractures. Furthermore, these agents are available in once-weekly formulations that provide patients with a convenient alternative to a daily dosage regimen. Alendronate and the selective estrogen-receptor modulator raloxifene provide considerable vertebral fracture protection after 1 year of treatment, and risedronate markedly reduces the rate of vertebral and nonvertebral fractures after 6 months of treatment. Data suggest that calcitonin-salmon nasal spray also reduces the risk of vertebral, but not nonvertebral, fractures. Raloxifene decreases the risk of nonvertebral fracture, but only in women with severe prevalent vertebral fractures. Although evidence supports the efficacy of hormone therapy, the risks should be carefully considered before treatment is begun. In addition to the antiresorptive therapies, teriparatide is a daily injectable anabolic treatment that is effective in reducing the risk of vertebral and nonvertebral fractures. Therefore, clinicians and patients have several options for reducing the risk of fracture and achieving optimal dosing convenience.

The Role of Calcium in Osteoporosis Drug Therapy

Great advances have been made in the field of osteoporosis treatment and prevention in recent years that have led to the availability of powerful new drugs. These drugs are viewed by patients and physicians as a major breakthrough in the management of osteoporosis. Unfortunately, this view has led many to ignore the importance of concurrent calcium supplementation to ensure the maximum benefit from these drugs, as evidenced by the recent decline in use of calcium supplements. As the majority of patients fail to consume the minimum recommended dietary intake of calcium, it is critical to recommend calcium supplements to raise total daily calcium intake to the levels needed to ensure maximum efficacy of osteoporosis treatments. Furthermore, osteoporosis drug labeling should be strengthened to encourage proper use of these drugs in combination with calcium supplements.

Comparison of cyclic and continuous calcitonin regimens in the treatment of postmenopausal osteoporosis

We aimed to compare and evaluate the efficacies of a continuous regimen of intranasal salmon calcitonin (SCT) and two cyclic regimens (different cyclic regimens from previous studies) based on alternating 15 days or on 10 days consecutively per month for 1 year in the treatment of postmenopausal osteoporosis. We performed an open-label, prospective, randomized clinical trial. A total of 120 postmenopausal osteoporotic participants between 50 and 65 years old were randomly assigned to one of three treatment groups. Patients in group 1 (n = 40) received continuously SCT nasal spray at a dose of 200 IU/day, plus continuously 500 mg/day elementary calcium and 0.25 microg/day 1-alpha hydroxyvitamin D3, for 1 year. Patients in group 2 (n = 40) received cyclically SCT nasal spray at a dose of 200 IU/day on alternating 15 days per month, plus continuously 500 mg/day elementary calcium and 0.25 microg/day 1-alpha hydroxyvitamin D3, for 1 year. Patients in group 3 (n = 40) received cyclically SCT nasal spray on 10 days consecutively per month (20 days/month rest), plus continuously 500 mg/day elementary calcium and 0.25 microg/day 1-alpha hydroxyvitamin D3, for 1 year. Data was evaluated by repeated analysis of variance (ANOVA). In addition, statistical differences between groups were assessed by the two-tailed Student's t test. After 1 year of the study, seven patients from group 1, eight patients from group 2 and five patients from group 3 withdrew from the study. No patient discontinued the study because of adverse drug effects. There was a statistically-significant improvement in pain intensity VAS scores at the end of the year to baseline scores in all three groups (p < 0.001). There was no significant difference in pain intensity VAS scores between groups at the end of the year (p > 0.05). Lumbar and femur neck BMD scores improved significantly at the end of treatment in all three groups (p < 0.05). There was no statistically-significant difference in BMD scores between groups at final (p > 0.05). Urinary DPD/Cre levels decreased significantly in all three groups by the end of the year (p < 0.05). There was no statistically-significant difference in urinary DPD/Cre final levels between groups (p > 0.05). According to the results of the present study, consecutive 10 days therapy with SCT, which is the first in the literature to our knowledge, is as effective as the other two regimens in the treatment of osteoporosis. Both cyclic regimens in our study (alternating 15 days and 10 consecutive days each month for 1 year) do appear to offer some advantages, especially economically and clinically, as compared to continuous treatment.

Perimenopause: More Than Hot Flushes and Night Sweats for Some Australian Women

OBJECTIVE

To identify the most common perimenopausal symptoms experienced by a group of Australian women and explore the extent to which those symptoms were distressing.

DESIGN

A quantitative survey.

SETTING

All women's health centers listed with the New South Wales Women's Information and Referral Service.

PARTICIPANTS

A convenience sample of 200 healthy women, aged 45 to 55 years, drawn from a statewide population of women residing in Australia.

MAIN OUTCOME MEASURE

The Women's Health Assessment Scale.

RESULTS

Most frequently occurring perimenopausal symptoms included forgetfulness, lack of energy, irritability, and weight gain. The most distressing perimenopausal symptoms included weight gain, heavy bleeding, poor concentration, leaking of urine, and feeling as though life were not worth living. Current use of hormone replacement therapy contributed to the prediction of both symptom occurrence and symptom distress.

CONCLUSION

Perimenopause is marked by more than hot flushes and night sweats; cognitive and affective changes are other distressing symptoms. The relationships between hormone replacement therapy use and both symptom occurrence and symptom distress warrant further investigation. In addition, practitioners should address concerns related to urinary incontinence, weight gain, cognitive and affective dysfunction, and general health status.

Hormonal Therapies and Osteoporosis

Osteoporosis, now defined as a disease characterized by low bone mass and a microarchitectural deterioration of bone tissue leading to enhanced bone fragility and fracture risk, is a major public health problem. Classic hormonal therapies to prevent and treat osteoporosis associated with menopause have recently been questioned due to the risk/benefit ratio of prolonged treatment. There is a critical need for safe and effective alternative therapeutics for this disease. Nonhuman primates have been used as models to assess bone changes associated with estrogen deficiency because their trabecular and cortical bone remodeling processes, monthly menstrual cycles, and reproductive-hormone patterns are similar to those of humans. The ovariectomized nonhuman primate has become the preferred model in which to study effects on bone remodeling, particularly with regard to bone mass, architecture, and strength, in fulfillment of studies required by international guidelines for the development of antiosteoporotic drugs. The nonhuman primate is amenable to several methodologies that assess bone quantity and quality, including dual energy x-ray absorptiometry (DXA), quantitative computed tomography (QCT), histology, static and dynamic histomorphometry, and biomechanical testing, as well as assays developed for clinical use, which serve as biomarkers of bone metabolic processes. The use of the nonhuman primate model in the assessment of osteoporosis therapeutics, both hormonal (sex steroids and their analogues, parathyroid hormone) and nonhormonal (bisphosphonates), has provided valuable information on the safety and efficacy as well as the mechanisms of bone loss associated with estrogen deficiency that is directly applicable to the human situation.