Evidence-based, best-practice guidelines for primary prevention of osteoporosis and osteoporotic fractures

Community health interventions aimed at increasing peak bone mass and decreasing lifelong bone loss could substantially reduce the incidence of osteoporosis and osteoporotic fractures. Before now, no evidence-based practice guidelines for primary prevention of osteoporosis and osteoporotic fractures have been produced for public health center workers, primary care providers, and community health specialists. We constructed guidelines that present the effects of life-style factors, such as food and nutritional intake, in (1) increasing peak bone mass among young adults, (2) minimizing bone loss among menopausal and postmenopausal women, and (3) preventing fractures among the elderly. To do this, we systematically reviewed relevant evidence on the effects of physique, milk, dairy products, vitamin K, vitamin C, vitamin A, magnesium, and isoflavones. The guidelines provide optimum intake values and recommendations for young adults, women, and the elderly.     

Osteoporosis in men: Are we ready to diagnose and treat?

Because osteoporosis and its attendant fractures are more common in women than in men, most studies have been performed in women. However, age-related osteoporosis and fragility fractures are also a major problem in men. Recent studies suggest that diagnosing men as osteoporotic when they fall more than 2.5 standard deviations below the mean for young men identifies a group at risk for fracture. Data suggest that many men with femoral fractures have age-related hypogonadism. Hypogonadism is associated with decreased lean body mass and bone mass. Most men with femoral fractures are reported to be hypogonadal. Testosterone replacement in hypogonadal older men improves bone mass and lean body mass. A therapeutic intervention to reduce fracture incidence in men with osteoporosis has been reported. No population-based study has examined the incidence or prevalence of hypogonadism with or without osteoporosis in men. Thus, osteoporosis in men probably exists with and without hypogonadism. Therapeutic interventions should be based on treatment of hypogonadism when present with osteoporosis.     

Skeletal involvement in adult patients with endogenous hypercortisolism

Overt endogenous glucocorticoid excess is a well-recognized cause of bone loss and osteoporotic fractures. Cortisol excess inhibits bone formation, increases bone resorption, impairs calcium absorption from the gut, and affects the secretion of several hormones (in particular gonadotropins and GH), cytokines, and growth factors, influencing bone metabolism. The glucocorticoid excess mainly affects trabecular bone, leading to vertebral fractures in up to 70% of patients. Osteoporotic fractures may be the presenting symptom of an otherwise silent glucocorticoid excess and can precede the diagnosis of hypercortisolism by up to 2 yr. The removal of glucocorticoid excess leads to a recovery of bone mass which is, however, often incomplete and delayed, although it reduces the risk of osteoporotic fractures. Bisphosphonate therapy has been suggested to be useful in maintaining bone mass in these patients. Subclinical hypercortisolism, a condition of impaired hypothalamic- adrenal-axis homeostasis without the classical signs and symptoms of glucocorticoid excess, is a recently defined entity, which has been shown to be associated to increased bone resorption, bone loss, and high prevalence of vertebral fractures regardless of gonadal status. However, data about the effect of this subtle glucocorticoid excess on bone are still scarce and conflicting. Moreover, it is not yet known whether removing the cause of subclinical hypercortisolism leads to a recovery of bone mass and reduces the risk of osteoporotic fractures. Finally, recent data suggest that subclinical hypercortisolism is a common and underrated finding in patients with established osteoporosis. In summary, it is crucial to evaluate the risk of osteoporosis and fractures in patients with glucocorticoid excess; on the other hand, it also seems advisable to screen for glucocorticoid excess patients with osteoporotic fractures without known secondary causes of osteoporosis.     

Pharmacological treatment of osteoporosis for people over 70

Osteoporosis has been defined as "a systemic disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with consequent increase in bone fragility and susceptibility to fracture". The impact of osteoporosis is most pronounced in elderly populations who run the greatest risk of fractures. The probability of developing mainly hip, vertebral and other non-vertebral fractures (for example, a Colles fracture) not only depends on bone mineral density (BMD) but also on age. Older patients are more susceptible to fracture than younger patients with the same BMD T-score. As the older population increases, the incidence of osteoporotic fractures is expected to rise dramatically over the next few decades. Although hip fractures are considered to be the most severe and economically important osteoporotic fracture, vertebral fractures also lead to adverse health outcomes, including back pain, height loss and kyphosis. These changes may result in significant declines in physical performance, function and, ultimately, loss of independence. The challenge for physicians is to prevent bone loss, to diagnose and treat osteoporosis before fractures occur, and to treat patients who have already experienced a fracture to prevent recurrent fractures. The objective of this review is to analyze the capacity to reduce fractures as the key element to evaluate the effectiveness of available medications: calcium and Vitamin D, bone formation drugs, antiresortive drugs, and dual-effect drugs. In view of the paucity of information about treatment of osteoporosis in the elderly population, available studies were not designed with this objective, so that this article reviews data mostly deriving from post-hoc analysis or sub-analysis of the main phase III clinical trials of each of the tested medications.     

Intervention in lifestyle factors for the prevention of osteoporosis and osteoporotic fractures

According that osteoporosis is the common condition in an aging society such as in Japan, much progress has been made in understanding the treatment and prevention of osteoporosis. Among potential risk factors, exercise, smoking, and alcohol consumption have been recognised as important lifestyle factors that might influence the risk of osteoporosis and osteoporotic fractures. To assess the relationship between these lifestyle factors and the risk for low bone mass and osteoporosis-related fractures, a systematic literature search over past 13 years was conducted. Accumulating evidence indicates that exercises decrease the risk for hip fractures among middle aged and older men and women. Exercises also help to maintain muscle strength, muscle volume, balance, and joint flexibility, which might prevent falls and fall-related fractures. One randomised controlled trial indicates that high-impact and/or weight-bearing exercise might increase the bone density in the elderly and the peak bone mass among young women. The literature search also address that there is an association between cigarette smoking and the risk of osteoporosis. Smoking cessation is effective to decrease the risk for both osteoporosis and osteoporotic fractures. Future research should be required to evaluate the alcohol consumption and osteoporosis.     

Pharmacological therapy of osteoporosis

The aim of pharmacological therapy for osteoporosis is to prevent osteoporotic fractures. Low bone mineral density, previous fractures, high values of bone turnover markers, and age are the independent risk factors for osteoporotic vertebral fractures. These clinical parameters should be utilized to start and choose the drugs for osteoporosis.     

Evaluation of exercise as a preventive therapy for osteoporosis

Osteoporosis and osteoporotic fractures have become an epidemic in the industrialized world. Osteoporosis, low bone mass, is a silent condition with microarchitectural deterioration of the bone structure leading to decreased bone strength and osteoporotic fractures. Physical activity has been advocated as offering a potential means to increase and maintain bone mineral density. Previous cross-sectional studies showed that there is a strong association between exercise and bone mineral density, especially in athletic individuals. However, there might be a self-selection bias; i.e. individuals with larger muscles and bones are more likely to choose an athletic lifestyle. Although there is a report that physical activity is associated with a reduced risk for hip fracture among older community-dwelling women, the effects of vigorous exercises building bone mass is modest and considerably less than bisphosphonates. The proper evaluation of exercise as a preventative therapy for osteoporosis should focus on prevention of falls or osteoporotic fractures.     

骨质疏松症及其骨折的局部治疗

骨质疏松症是一种以骨量减少和骨强度降低为表现的骨骼疾病,骨质疏松症患者骨折的风险性显著增加。每年大约有2000万人受到该种疾病的折磨。骨质疏松症是一种无声无息的疾病,往往不被重视和治疗,直到其引起骨折。该病目前主要的治疗手段仍有赖于系统用药以阻止骨密度和骨量的进一步丢失。骨质疏松症的局部治疗是一种新的治疗手段,其通过在易于发生骨质疏松性骨折的部位应用抗骨质疏松药物和促进骨形成的细胞因子或生物材料,达到提高局部骨质疏松骨的骨密度、改善骨微结构和生物力学性质的目的 。     

Bone mass is low in relatives of osteoporotic patients

STUDY OBJECTIVE: To determine whether the failure to attain normal bone mass in young adulthood contributes to the later development of osteoporotic fractures. DESIGN: Case-control study. SETTING: Referral-based bone clinic at a large teaching hospital. PATIENTS: Sequential sample of 35 asymptomatic relatives, aged 19 to 59 years, of patients with osteoporotic fractures, and 24 patients with osteoporotic fractures. MEASUREMENTS AND MAIN RESULTS: Bone mineral density in the spine was measured by quantitative computed tomographic scanning. Bone mineral content in the os calcis was measured in 19 of the relatives of osteoporotic patients by single-photon absorptiometry. The values for bone mineral density in the spine were corrected to age 50 years with the regression equation derived from the normal values in the controls. The values were lower in relatives of osteoporotic patients than in controls. In men, the mean values (+/- standard deviation [SD]) for relatives were 91 +/- 16 mg/cm3, and for controls, 129 +/- 21 mg/cm3 (P less than 0.001). In women, the mean values for relatives were 96 +/- 17 mg/cm3 and for controls, 126 +/- 19 mg/cm3 (P less than 0.001). In the osteoporotic patients, the corrected mean value for men was 53 +/- 12 mg/cm3, and for women, 77 +/- 20 mg/cm3. The os calcis values did not correlate with the spine values and were mostly well within the normal range. CONCLUSIONS: Mean bone mass is lower in apparently healthy young and middle-aged adult relatives of osteoporotic patients than in normal persons with no family history of osteoporosis. Our findings suggest that the failure to attain an adequate peak bone mass may play an important role in the later development of osteoporotic fractures. Relatives of osteoporotic patients should be advised to have measurements of bone mass taken. This measurement should be taken at the spine, because peripheral sites do not appear to provide adequate information about early osteoporosis.     

Osteoporosis in men

Osteoporosis is characterized by a reduction in bone density, associated with skeletal fragility and an increased risk of fracture after minimal trauma. Although osteoporosis is generally considered to be a condition affecting post-menopausal women, it is now clear that substantial bone loss occurs with advancing age in men, such that up to 20% of symptomatic vertebral fractures and 30% of hip fractures occur in men. This chapter highlights the incidence and prevalence of osteoporotic fractures in men and reviews the associated morbidity, excess mortality and health and social service expenditure. The determinants of peak bone mass and bone loss in men are discussed, as is the pathogenesis of osteoporosis and vertebral and hip fractures. The criteria for the diagnosis of osteoporosis in men are reviewed, together with the most appropriate investigations for secondary osteoporosis. The management of osteoporosis in men is also discussed, highlighting the most appropriate treatment options.     

Osteoporosis in Korea

The increasing occurrence and high cost of osteoporosis pose an enormous public health problem. With continued aging of the populations, osteoporotic fractures may reach one of the major problem in Korea as well as in Asian countries. Although the prevalence of osteoporosis in Korea is somewhat not consistent because of different areas and machines measured bone mass, occurrence of hip fractures have increased about 4 folds during past 10 years. There is no satisfactory way to build up lost bone, thus, prevention is the best way which includes adequate intake of calcium, vitamin D, and protein, exercise, and stop smoking. As a second approach, pharmacologic therapy may be emphasized. Since most of pharmacologic agents for osteoporosis are available in Korea though their reimbursements are limited, preventive measures and pharmacologic therapies should be encouraged to attempt to reduce fragility fractures. Many doctors who work in the field of bone metabolism are establishing the new guidelines for osteoporosis and also attempt to revise the criteria for reimbursement nowadays. New paradigm for osteoporosis will be come and be utilized for clinical applications in the near future.     

Osteoporosis in men

Osteoporosis is defined as "a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture". Approximately 40-50% of women sustain osteoporotic fractures in their lifetime; as such, it is appropriate that studies initially focused upon females. Despite an increased recognition of osteoporotic fractures in men, there continues to be neglect of this disease in males. This ongoing neglect is inappropriate as 25-33% of men in some populations will sustain osteoporotic fractures in their lifetime. Testosterone plays an important role in male skeletal health. However, recent data suggest that estrogen may in fact be the dominant hormone regulating skeletal status in both men and women. BMD measurement may be utilized for osteoporosis diagnosis and to assist with fracture risk prediction in men prior to their sustaining a fracture. Recognizing this need, the International Society for Clinical Densitometry (ISCD) recommended and recently reaffirmed use of a BMD T-score of -2.5 or below be utilized to diagnose osteoporosis in men. Androgen therapy of hypogonadal men may be considered with the caveat that data do not exist to document that this treatment reduces fracture risk. At this time, the data is inadequate to support use of androgen treatment in eugonadal men with osteoporosis. Parathyroid hormone treatment does increase BMD; existing studies have not been of adequate size or duration to document fracture reduction efficacy. Bisphosphonate therapy increases BMD, reduces vertebral fracture risk and is considered the standard of care for osteoporotic men at this point in time.     

Physiopathology and etiology of osteoporosis

Most of the research on osteoporosis has concentrated on the etiology of the decrease in bone mass. One of several important factors is bone fragility. Genetic and racial factors are important but are modified by environmental factors such as dietary calcium, body weight, and physical activity. Methods of bone mass measurement currently available show some overlap between bone mass in osteoporotic patients who have sustained fractures and normal persons without fractures. However, these methods do have a predictive value in determining a person's risk of future fractures (in the spine or elsewhere).     

Advances in osteoporosis: better identification of risk factors can reduce morbidity and mortality

Johnell O (Department of Orthopaedics, Malmö University Hospital, Malmö, Sweden). Advances in osteoporosis: better identification of risk factors can reduce morbidity and mortality (Review). J Intern Med 1996; 239: 299–304.
Osteoporosis is a common disease of postmenopausal women and the elderly. Low bone mass results from genetic, nutritional and lifestyle factors, decreased oestrogen levels, certain medical conditions, and the use of certain drugs. The overall incidence and age-and sex-related incidences of osteoporosis are increasing worldwide. Osteoporotic fractures can cause considerable pain, disability, loss of independence and deterioration in quality of life. Many patients lose the ability to perform the activities of daily living. Mortality and morbidity after hip fracture increase with age. Prevention of osteoporosis and osteoporotic fractures is an urgent priority to reduce the burden placed on health care and social welfare systems.     

Osteoporosis in men: update 2011

During the past year several review articles have been published on the topic of osteoporosis in men. These reviews have highlighted recommendations for measuring bone mineral density (BMD) in older men as a means of screening for osteoporosis, use of the World Health Organization's Fracture Risk Assessment Tool for predicting the risk of hip and major osteoporotic fractures, frequency of secondary causes of osteoporosis, useful laboratory tests to evaluate these conditions, newer treatments for men with osteoporosis that increase BMD and may reduce the risk of fractures, and new data on the prevalence of low BMD and osteoporosis in men.     

Physiotherapie und Bewegung bei Osteoporose und Folgeerkrankungen

Osteoporosis is defined by decreased bone strength and increased susceptibility to fracture. Fractures and their consequences are the clinical manifestation of osteoporosis. Acute and chronic pain, functional limitations including permanent impairment and the need for long-term care may be caused by osteoporotic fractures. The aim of osteoporosis treatment is to prevent fractures by bone strengthening. The aims of rehabilitation in patients with osteoporosis are to reduce pain, maximize the level of musculoskeletal function, particularly following fractures, decrease risk of falls and optimize quality of life and independence. Certain sports and exercises greatly promote skeletal development in children and adolescents and augment bone strength in adults. Physiotherapy and therapeutic exercise may relieve pain, increase musculoskeletal function and form an important part of fall management.     

Are calcium and vitamin D supplements for everyone?: Pro

Calcium and vitamin D are essential for the health of our bones and various scientific societies recommend an intake of 1,000 mg of calcium and 800 IU of vitamin D daily. Most people with osteoporosis do not eat food with this amount of calcium and also have insufficient levels of vitamin D, so supplements are recommended to provide osteoporotic patients with these amounts. Calcium supplements and vitamin D improve the effectiveness of anabolic and anti-catabolic agents and may have a small effect in reducing the number of fractures. Calcium supplements alone have not shown efficacy preventing fractures in patients with osteoporosis and may increase cardiovascular risk in healthy elderly women and is therefore not recommended for widespread use. Vitamin D supplements are recommended in persons with 25-OH vitamin D levels below 30 ng/ml, in particular the elderly and osteoporotic patients, due to its ability to halt the remodeling resulting from secondary hyperparathyroidism and reduce the loss of bone mass. Vitamin D supplements could help reduce falls and fractures in the institutionalized elderly. In addition, supplements of vitamin D may have other beneficial effects due to extra-osseous regulatory functions on the immune response and cell differentiation and proliferation that is associated with vitamin D. Trials begun in recent years clearly indicate a beneficial effect of vitamin D supplements on mortality, cardiovascular risk,development of tumors and prevention of infections.     

Concentration of insulin-like growth factor (IGF)-I in iliac crest bone matrix in premenopausal women with idiopathic osteoporosis.

Previous studies have shown a link between low serum insulin-like growth factor-I (IGF-I) and decreased bone mass of patients with osteoporosis. However, whether serum levels are representative for the growth factor concentration or activity available in human bone tissue is controversial. In the present study, IGF-I was assessed in serum and bone matrix extracts from the iliac crest in 19 eugonadal women with idiopathic osteoporosis and in 38 age-matched controls. In addition, the relationship between the skeletal levels of IGF-I and bone mineral density (BMD) or the susceptibility to osteoporotic fractures in women with osteoporosis was examined. Bone matrix extraction was performed based on a guanidine-HCL/ethylendiamine-tetraacetic acid (EDTA) method. No significant difference in both serum and bone matrix IGF-I levels between groups was observed. Serum IGF-I concentrations failed to be associated with bone matrix IGF-I levels in osteoporotic patients. However, in premenopausal women with idiopathic osteoporosis, skeletal IGF-I positively correlated with BMD at the lumbar spine (r = + 0.58, p = 0.01). In contrast, neither femoral neck BMD nor Ward's triangle BMD was associated with bone matrix IGF-I concentrations. A tendency towards lower levels of bone matrix IGF-I in subjects with vertebral fractures as compared to those without fractures was observed in age-adjusted analyses, however the difference failed to remain statistically significant after adjustment for bone mineral density. These data provide no clear evidence for low bone matrix IGF-I as a determinant factor of age-unrelated osteoporosis. However, low skeletal IGF-I concentrations may aggravate osteoporosis in these women.     

Background for studies on the treatment of male osteoporosis: state of the art

Male osteoporosis represents an important, although long underestimated, public health problem. Both in men and in women aging is accompanied by continuous bone loss and by an exponential increase in the incidence of osteoporotic fracture, with a female to male incidence ratio of about 2 to 3 to 1 in the elderly for hip and vertebral fractures. Morbidity after osteoporotic fractures appears to be more serious and mortality more common in men than in women. To date, no single treatment has been proved to be effective and safe in published prospective studies. The present report, based on a systematic search of the literature on male osteoporosis, summarises the state of the art on the clinical consequences of male osteoporosis and its risk factors, in relation to the present state of knowledge about female osteoporosis. This constitutes the background for the design of rational clinical development strategies for therapeutic interventions in male osteoporosis. From this review of the literature it is apparent that notwithstanding the existing sex differences in pathophysiology of osteoporosis and the difference in age-specific incidence of osteoporotic fractures, there are also important similarities between osteoporosis in women and men. The higher incidence of fracture in women than in men results from quantitative differences in risk factors rather than from different risk factors. Even though there are sex differences in bone geometry, incidence of fracture seems to be similar in men and women for a same absolute areal bone mineral density. However, the lack of data on the changes in fracture rates in men resulting from pharmacological intervention, leading to changes in bone mineral density or bone turnover, remains the main limitation for extrapolation of established treatment outcomes from women to men.