Should patients with coeliac disease have their bone mineral density measured?

BACKGROUND: In 1998 we published guidelines for managing osteoporosis in coeliac disease. These guidelines recommended bone mineral density (BMD) measurement at diagnosis. We analyse the results of following these guidelines in a district general hospital with a view to rationalizing screening. PATIENTS AND METHODS: Forty-three consecutive patients with newly diagnosed coeliac disease had dual-energy X-ray absorptiometry scans of the hip and lumbar spine. Results were correlated with factors that were suspected to influence BMD and were compared with comparable published studies. RESULTS: Osteoporosis at the hip and spine was found in only 7% and 14% of patients, respectively. Mean z scores were not significantly reduced. BMD did not correlate with the duration of gluten exposure, symptoms, degree of villous atrophy, or smoking. At the hip, but not at the spine, there was a significant correlation between BMD and the body mass index. CONCLUSIONS: The surprisingly low yield of reduced BMD, together with doubt about increased fracture rates in coeliac patients, does not support the current recommendations for screening BMD at diagnosis, and the guidelines should be changed.     

Do patients receive appropriate information and treatment following bone mineral density measurements?

SIR, There is no policy for osteoporosis screening in the UK.It is generally recommended that bone density measurements betargeted towards high-risk groups [1] since it is not appropriateor effective to treat on the basis of clinical risk factorsalone [2]. We offer an open access bone densitometry service measuringlumbar spine and total hip bone mineral density (BMD) usingdual-energy X-ray absorptiometry (DXA). Patients are also askedto complete a risk-assessment questionnaire. Using informationfrom the referral form, BMD measurement and patient questionnairean individualized     

Klinefelter's syndrome and bone mineral density: is osteoporosis a constant feature?

Objectives

Data on bone mineral density (BMD) in Klinefelter syndrome (KS) are scarce and contradictory. The aim of the present study was to investigate BMD in patients with KS and in healthy controls with special attention to gonadal status.

Material and methods

We investigated 26 patients with KS (30 ± 9 yr) who had never been treated with testosterone. Thirty-nine age-matched healthy males served as controls. We assessed BMD by performing dual energy X-ray absorptiometry and measured serum hormone levels, including total testosterone (T), free testosterone, estradiol (E2), leptin. The estrogen to androgen ratio (E2/T) was used as an indirect measure for aromatase activity.

Results

No difference was found in BMD at femoral neck (1.06 ± 0.16 vs 1.04 ± 0.14 g/cm²), or at lumbar spine (1.00 ± 0.09 vs 1.03 ± 0.11) between patients and controls. Two patients and one control were classified as osteoporotic (T-score ≤ −2.5). Compared with controls, patients had lower levels of T and free testosterone, similar E2 levels, and increased E2/T (P < 0.05). In KS patients, leptin was significantly higher and correlated positively with E2/T (r = 0.484, P = 0.02). E2/T correlated with femoral neck BMD (r = 0.566, p = 0.02), T and free T correlated with lumbar spine BMD (r = 0.433, P = 0.05 and r = 0.534, P = 0.05).

Conclusion

Osteoporosis is not a constant feature in young patients with KS, even without testosterone substitution. The aromatisation of T into E2, related to adiposity, may contribute to the achievement and maintenance of normal BMD in some KS patients.     

Is leptin a significant predictor of bone mineral density in postmenopausal Turkish women?

The objective of the present study was to investigate the relationship between leptin and bone mineral density in postmenopausal Turkish women. A total of 122 healthy postmenopausal women were enrolled in this cross-sectional study. Blood samples were obtained for analysis of serum leptin. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the lumbar spine, femoral neck and trochanter on the same day. Leptin levels was significantly correlated with BMD of L(1-4) (P = 0.04), but not of femoral neck (P = 0.13), and trochanter (P = 0.39). However, Z scores of L(1-4) (P = 0.009), femur neck (P = 0.009), and femur trochanter (P = 0.025) were positively correlated with leptin levels. In multiple linear regression analysis, leptin was not found to be a statistically significant independent predictor for BMD. Leptin was associated with BMD and Z scores at various body sites; however, it was not an independent predictor of BMD.     

Ankylosing spondylitis and bone mineral density—what is the ideal tool for measurement?

Ankylosing spondylitis (AS) is characterised by chronic inflammation and partial ossification, yet vertebral fractures due to osteoporosis, although common, are frequently unrecognised. The aim of this study was to (1) show the frequency of changes in the progress of osteopenia/osteoporosis in AS depending on duration and stage of the disease and (2) assess the ranking of two different methods of bone density measurement in this clinical pattern. We measured bone density in 84 male and female patients with both dual X-ray absorptiometry (DXA) and single energy quantitative computed tomography (SE-QCT). In the initial and advanced stages of the disease, a high decrease in axial bone density could be verified (DXA: osteopenia in 5% and osteoporosis in 9.2%; SE-QCT: osteopenia in 11.8% and osteoporosis in 30.3%). Peripheral bone density decrease as in osteopenia could be proven in 17.6% by DXA measurement. With SE-QCT, a decrease in vertebral trabecular bone density could already be observed in the initial stage and continued steadily during the course of the disease; cortical bone displayed the same trend up to stages of ankylosis. With DXA, valid conclusions are more likely to be expected in less marked ankylosing stages of AS. In stages of advanced ankyloses in the vertebral region (substantial syndesmophytes), priority should be given to SE-QCT, due to the selective measurement of trabecular and cortical bone. The DXA method often yields values that are too high, and the replacement of vertebral trabecular bone by fatty bone marrow is not usually recorded as standard. There may already be an increased risk of bone fracture in AS in osteopenia on DXA along with an osteoporosis already established on SE-QCT.     

Does subclinical hypercortisolism adversely affect the bone mineral density of patients with adrenal incidentalomas?

OBJECTIVE: Subclinical hypercortisolism (SH) is detected increasingly in a substantial proportion of patients with incidentally discovered adrenal adenomas. The clinical implications of SH are currently unclear. Osteoporosis is a well-known complication of glucocorticoid excess. So far, the impact of SH on bone mineral density (BMD) has been studied in a limited number of reports with discordant results. In the present study we evaluated the BMD in a large cohort of post-menopausal women with adrenal incidentalomas. : patients and measurements Forty-two post-menopausal women with incidentally discovered adrenal masses and radiological features highly suggestive of benign adrenal adenomas were investigated. All patients underwent a standard low-dose dexamethasone suppression test (LDDST; 0.5 mg 6-hourly for 2 days). The diagnosis of subclinical hypercortisolism (SH) was based on post-LDDST cortisol concentrations of > 70 nmol/l. According to this criterion patients were subdivided into two groups: with (n = 18; group A) or without (n = 24; group B) SH. There was no significant difference in age, years since menopause and body mass index between these groups. BMD was measured at L2-L4 vertebrae and three sites of the proximal femur by the dual energy X-ray absorptiometry (DEXA) method. RESULTS: Post-menopausal women with SH (group A) exhibited slightly but significantly lower absolute and age-adjusted BMD values compared to group B patients in the femoral neck (BMD g/cm2: 0.72 +/- 0.08 vs. 0.79 +/- 0.09; Z-score: -0.20 +/- 0.82 vs. +0.43 +/- 0.94, P < 0.05) and trochanter (BMD g/cm2: 0.60 +/- 0.09 vs. 0.69 +/- 0.10; Z-score: -0.32 +/- 1.0 vs. +0.30 +/- 1.05, P < 0.01). BMD measurements of the Ward's triangle were also lower in group A patients but the difference did not reach statistical significance (BMD g/cm2: 0.60 +/- 0.10 vs. 0.68 +/- 0.13, P = 0.06). There was no difference in the lumbar vertebrae between the two groups (BMD g/cm2: 0.888 +/- 0.13 vs. 0.90 +/- 0.16, P = 0.78; z-score: +0.50 +/- 1.16 vs. +0.11 +/- 1.5, P = 0.36). The number of patients in the osteoporotic range was minimal with no significant difference between the two groups. However, the frequency of osteopenia in group A was significantly greater than in group B patients in the trochanter and Ward's triangle areas. Serum osteocalcin (BGP) levels were significantly lower in group A compared to group B patients (18.6 +/- 8.6 vs. 26.2 +/- 8.1 ng/ml, P < 0.01); no difference existed regarding parathyroid hormone (PTH) concentrations (43 +/- 15.6 vs. 41.2 +/- 14.8 pg/ml, P = 0.72). CONCLUSIONS: In this series, post-menopausal women with subclinical hypercortisolism had lower absolute and age-adjusted BMD values and a higher rate of osteopaenia in the trabecular loaded and mixed cortical-trabecular bone of proximal femur. These data demonstrate that the subtle hypercortisolism of patients with adrenal incidentalomas may have an adverse effect on the bone mass of these patients.     

Lactose intolerance: a risk factor for reduced bone mineral density and vertebral fractures?

Background: The purpose of the present study was to determine differences, if any, in bone mineral density, the risk of fracture, and clinical behavior in patients with lactose intolerance investigated by hydrogen breath test. Methods: The study population (n = 218; age, mean ± SD, 58.2 ± 11.5 years) consisted of 103 healthy individuals negative hydrogen breath test (ΔH2 0–20 ppm; group I), and 115 individuals with evidence of lactose intolerance according to the hydrogen breath test (ΔH2 > 20 ppm), of whom 40 individuals had test results of 20 ppm < ΔH2 < 59 ppm (group II). The remaining 75 individuals were strongly positive on the hydrogen breath test (ΔH2 > 60 ppm; group III). The entire study population was measured for bone mineral density in the nondominant forearm and in the vertebra (quantitative computed tomography [qCT]). Radiographs of the spine were studied for fractures. Results: In healthy individuals, bone mineral density in the vertebra assessed by qCT (mean ± SD, 111.2 ± 31 mg/cc) did not significantly differ between those with mild (qCT, mean ± SD, 109.8 ± 35 mg/cc) and those with severe (qCT, mean ± SD, 107.7 ± 36 mg/cc) lactose intolerance. Lactose-intolerant individuals had more vertebral fractures per patient when compared with those with mild lactose intolerance or controls (P < 0.05). Considering vertebral and self-reported nonvertebral fractures, no statistically significant differences were found. In the entire group, the overall occurrences of fracture in the presence of lactose intolerance and in controls were comparable after correction for age and body mass index (BMI). Conclusions: Individuals with lactose intolerance verified by the hydrogen breath test appear not to be at risk for accelerated bone loss. Nevertheless, a relationship between vertebral fractures and an apparent lactose intolerance cannot be excluded, as a few individuals with severe lactose intolerance had a large number of vertebral fractures. Received: December 13, 2001 / Accepted: May 17, 2002     

Bone assessment in elderly women: what does a low bone ultrasound result tell us about bone mineral density?

Access to dual energy X-ray absorptiometry (DXA) can prove difficult for frail or elderly patients, and bone ultrasound may offer a practical alternative. Even after adjustment for bone mineral density (BMD), ultrasound readings are able to predict hip fracture in elderly women. We consider how bone ultrasound might contribute to bone assessment in a clinical setting. DXA remains the gold standard for bone assessment, with osteoporosis defined as a BMD result more than 2.5 S.D. below the young adult mean. Using an equivalent approach we defined an osteoporotic ultrasound result as broadband ultrasound attenuation (BUA)<54 dB/MHz. In 73 women aged 29-86 (mean 65) years DXA was used to measure BMD at lumbar spine and hip, and ultrasound to measure BUA at the heel. Correlation of BUA with BMD at femoral neck (r=0.64, P<0.001), and lumbar spine (r=0.55, P<0.001) was consistent with previously reported figures for this ultrasound system. All subjects with BUA below the 54 dB/MHz threshold value were shown to have low femoral neck BMD. Women (42%) aged over 65, but only 18% of younger women had low BUA results. In women over 65 years of age measurements of BUA achieved a sensitivity of 61% and specificity of 100% in prediction of low femoral neck BMD. Although a normal BUA did not exclude an osteoporotic BMD result at hip or lumbar spine, a low BUA appeared a highly specific predictor of low BMD at these sites. Since all those women identified as having a low BUA at the heel also had low BMD results, ultrasound appeared to identify a subgroup of elderly patients at a very high risk of fracture.     

Effects of 1-year anti-TNF-α therapies on bone mineral density and bone biomarkers in rheumatoid arthritis and ankylosing spondylitis

Clinical Rheumatology - Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) have been associated with generalized and localized bone loss. We conducted a comprehensive study using imaging...