Bone densitometry in children with idiopathic nephrotic syndrome on prolonged steroid therapy: A tertiary multicenter study

Long-term glucocorticoids administration inhibits bone mineralization and has a negative impact on basic cellular mechanisms that are critical in the development and maintenance of bone strength. Steroids can cause osteoporosis in children and have a negative impact on bone mineral content (BMC) and bone mineral density (BMD).We aim to determine the BMD of children with idiopathic nephrotic syndrome (INS) who are on corticosteroids therapy.This cross-sectional study included 90 patients on corticosteroids therapy and 50 apparently healthy age and sex-matched children served as a control group. Renal functions, bone biochemistry, and parathyroid hormone (PTH) were measured in patients and controls. BMD was measured at the lumbar spinal region (L2–L4) using Dual-energy X-ray absorptiometry (DEXA) scan in both patients and controls groups.Serum PTH, phosphorous, and alkaline phosphatase levels were significantly higher in patients than in controls. There was a statistically significant reduction in blood calcium levels in patients compared to controls. Osteopenia was diagnosed by DEXA scan in 24 patients (26.7%) and osteoporosis in 12 patients (13.3 %). There was a statistically significant decline in BMD-z score, BMD, and BMC in patients compared to the healthy group.Patients with INS on corticosteroids treatment have a lower BMD than their peers. Pediatric INS patients had a high prevalence of osteopenia and osteoporosis as measured by DEXA. Steroid therapy has a deleterious impact on bone mineralization in children with INS.     

二膦酸盐治疗对骨质疏松性骨痛、骨密度、骨强度的疗效及安全性评价

目的 观察两种二膦酸盐药物在治疗妇女绝经后骨质疏松性骨痛、骨密度、骨强度及骨折中的作用，评价其疗效及安全性。方法 202例绝经后骨质疏松患者简单随机分成3组，阿仑膦酸钠(福善美)组65例、依替二膦酸盐(依膦)组67例和钙尔奇D(钙剂)组70例，治疗1年。治疗前后采用双能X线骨密度测量仪(DEXA)测量腰椎、髋部骨密度(BMD)及椎骨形态，桡骨、胫骨超声骨密度测定，检测血钙、磷、碱性磷酸酶(BAP)、尿I型胶元交联N端肽(NTX)。观察骨痛改善程度、骨量变化、骨强度改变、新骨折发生和不良反应。结果 福善美组和依膦组治疗后骨痛均明显改善，福善美组改善时间7～10天，依膦组约2周左右，钙剂组疼痛变化不明显。福善美组治疗12个月后骨量增加6．9％，依膦组增加3．9％，钙剂组减少0．3％。福善美组桡骨及胫骨超声声速(SOS)值分别增加0．8％和1．2％，依膦组变化不明显，钙剂组则分别下降0．5％和2．9％。福善美组无新骨折发生，依膦组有3例、钙剂组有5例发生新骨折。福善美组和依膦组不良反应主要为上消化道症状，依膦组较明显；钙剂组主要为便秘。结论 福善美能明显缓解骨质疏松性骨痛，显著提高骨密度，增加骨强度，预防骨质疏松性骨折的发生。     

36 month intermittent cyclical etidronate treatment in patients with established corticosteroid induced osteoporosis.

OBJECTIVE: To determine the longterm safety and efficacy of etidronate therapy in patients in whom corticosteroid induced bone loss has already occurred. METHODS: We performed a 36 month observational cohort study in which all data were obtained from Canadian Database of Osteoporosis and Osteopenia (CANDOO) patients. The etidronate group consisted of 24 patients who received 400 mg of etidronate disodium for 14 days, followed by 76 days of calcium carbonate (500 mg of elemental calcium), repeated every 3 mo; the control group included 37 patients who received calcium carbonate 500 to 1000 mg daily. Outcome measurements included changes within groups from baseline and differences between groups in the bone mineral density (BMD) of the lumbar spine, femoral neck, and trochanter at 12, 24, and 36 months. The incidence of vertebral fractures was also determined. RESULTS: Etidronate therapy resulted in a meaningful percentage increase from baseline in lumbar spine BMD, primarily during the first 24 months of treatment, and this increase was sustained for the remainder of the 36 month study period (5.2%; p = 0.016). Analysis of covariance revealed a significant percentage difference (SD) between groups in lumbar spine BMD at 12 [5.5 (13.5) percent; p = 0.003] and 24 months [6.0 (17.4) percent; p = 0.011] in favor of the etidronate group. After 3 years of therapy, one patient (4%) experienced one vertebral fracture in the etidronate group, whereas 3 patients (8%) experienced 5 vertebral fractures in the control group. CONCLUSION: Etidronate treatment administered for 36 months reversed lumbar spine bone loss, and appeared to be safe in patients with established corticosteroid induced osteoporosis.     

Continuous combined oestrogen/progestin therapy is well tolerated and increases bone density at the hip and spine in post-menopausal osteoporosis

OBJECTIVES Although oestrogen/progestin therapy is effective prophylaxis against post-menopausal osteoporosis, its efficacy in the treatment of established disease is uncertain. In addition, cyclical oestrogen/progestin regimens are associated with low rates of patient acceptance. The present study assesses the acceptability of, and skeletal response to, continuous combined hormone replacement therapy in osteoporotic late post-menopausal women. DESIGN Retrospective, controlled study. PATIENTS One hundred and four osteoporotic late postmenopausal women treated with continuous combined hormone replacement therapy (5 mg medroxyprogester-one acetate daily and either 0·625 mg oral conjugated oestrogens or 50 μg transdermal oestradiol daily) were followed for an average of 1 year (range 2–38 months). Control subjects were 19 healthy normal women matched for menopausal age and weight. MEASUREMENTS Adverse effects and compliance rate were monitored. Baseline and 1-year measurements of lumbar spine bone mineral density (BMD) were performed using dual-energy X-ray absorptiometry in 51 women, 22 of whom also had measurements at 2 years. Twenty-eight women had proximal femur scans at baseline and 1 year. RESULTS Eighty-six per cent of women continued to take continuous combined hormone replacement therapy at the end of follow-up. Mastalgia (44%) and vaginal bleeding (29%), the most common side-effects, were minor and self-limiting in virtually all women. Spinal BMD increased by 7·1 ± 0·8% (mean±SEM P < 0·001) at 1 year and by 8·9 ± 1·5% (P < 0·001) at 2 years. In the proximal femur, BMD increased by 2·9 ± 0·9% at the femoral neck (P= 0·01) and by 2·5±0·9% (P= 0·001) at the trochanter at 1 year. BMD tended to decline in the control group. Among the women taking hormone replacement therapy, the increase in spinal BMD was similar in those treated with 0·3–0·44 mg/day of conjugated equine oestrogens to those receiving 0·45–0·625 mg/day. CONCLUSION Continuous combined hormone replacement therapy is an acceptable therapy to osteoporotic late post-menopausal women and produces substantial increases in lumbar spine and proximal femoral bone mineral density.     

Effects of raloxifene on bone mineral metabolism in postmenopausal Japanese women on hemodialysis

In addition to renal osteodystrophy, postmenopausal women on hemodialysis are at high risk for osteoporosis. Recent studies reported the effects of raloxifene, a selective estrogen receptor modulator for osteoporosis, in postmenopausal women. The present study evaluated the efficacy of raloxifene and its effects on bone mineral metabolism in postmenopausal Japanese patients on dialysis. In a prospective, multicentre study, 17 postmenopausal women on chronic hemodialysis with severe osteoporosis (bone mineral density [BMD]≤2 SD by bone densitometry) were treated with 60 mg/day raloxifene hydrochloride for 12 months. The study also included 10 age-matched control women. Vitamin D and calcium salts were not changed during the study. Intact parathyroid hormone (iPTH), serum calcium and phosphorus, and bone resorption marker (NTx) were measured, and BMD were determined by DEXA, at 0, 6, and 12 months after administration of raloxifene. The mean lumbar spine BMD at baseline was similar in the two groups. Raloxifene therapy (for 12 months) improved lumbar spine BMD (by 2.6%) in 53% of the patients, while 70% of the control group showed a reduction in BMD (by 4.0%). Raloxifene significantly decreased serum calcium and increased iPTH. Our results suggested that raloxifene improved trabecular BMD in postmenopausal Japanese women on hemodialysis. The effects of raloxifene on serum calcium and serum iPTH level suggest it improves bone resorption. Vitamin D and/or calcium salts should be added to raloxifene treatment to avoid secondary hyperparathyroidism.     

Reduced bone mineral density after surgical treatment for obesity.

OBJECTIVE: To investigate whether osteoporosis occurs after surgical treatment for obesity. DESIGN: A cross-sectional study of five groups of subjects who had undergone surgical treatment for obesity: five pre-menopausal women; 13 post-menopausal women; seven post-menopausal women taking oestrogen replacement (HRT); five men; and six women who had undergone surgical reversal (mean time 7 y). SUBJECTS: Thirty-six Caucasian subjects who had undergone jejunoileal or pancreaticobiliary bypass surgery at St George's Hospital between 1971 and 1992. Their mean age was 50.8 y (range 32-69 y) and the median time since the operation was 14.8y (range 4-23 y). MEASUREMENTS: A clinical questionnaire was used to exclude possible factors, which might influence bone mineral density. A single blood sample was collected for measurement of calcium, phosphate, alkaline phosphatase, albumin, magnesium, zinc, creatinine, thyroxine, 25-hydroxy-vitamin D, sex steroids, gonadotrophins and IGF-1 and 24 h urine calcium excretion was measured. Bone mineral density (BMD) was measured in the lumbar (L2-L4) spine (LS) and femoral neck (FN) by dual energy X-ray absorptiometry (DEXA). RESULTS: There was no difference in serum calcium, alkaline phosphatase, IGF-1, 25-hydroxy-vitamin D (25-OH vitamin D), magnesium or zinc concentrations between the five groups. The LS-BMD T score was lower (P < 0.05) in male subjects ( -2.08 +/- 1.04 mean 1.0 +/- s.d) and post-menopausal women not taking HRT ( -1.21 +/- 1.33) compared to the surgically reversed group (0.87 +/- 2.36). The male group was most severely affected, despite normal serum testosterone concentrations. Two of the five men studied, had a LS-BMD T score < -2.5 and two had a LS-BMD T score between -1.0 and -2.5. In contrast, six of the seven post-menopausal women on HRT had an LS BMD T score > - 1.0. There was no difference in the FN-BMD between the five groups. The presence of low BMD was not related to age, duration of bypass, or degree of postoperative weight loss. Iliac crest bone biopsies in three subjects with low BMD, confirmed the presence of osteoporosis. CONCLUSIONS: Reduced bone mineral density is a complication of jejunoileal bypass surgery.     

A Canadian survey on the management of corticosteroid induced osteoporosis by rheumatologists

OBJECTIVE: To survey the practice pattern of Canadian rheumatologists (CR) on their management of corticosteroid induced osteoporosis in their premenopausal (PrM) and postmenopausal (PoM) female patients. METHODS: The practice pattern was surveyed using a 17 item questionnaire probing the diagnosis, prevention, treatment, and monitoring of osteoporosis in PrM and PoM women receiving longterm oral systemic corticosteroid therapy. RESULTS: Most CR investigated and treated osteoporosis themselves, 13% referred to other specialists for investigation, and 22% referred for treatment. Eighty-two percent of CR used dual energy x-ray absorptiometry (DEXA) to confirm a diagnosis of osteoporosis. Most CR initiated investigation for osteoporosis at the start or within the first year of starting longterm systemic corticosteroid therapy: PrM 87% and PoM 93%. The most frequently used initial strategy for the prevention of osteoporosis was as follows. PrM: calcium and vitamin D3 (53%); PoM: hormone replacement therapy (HRT) and calcium (29%). The most common initial choice for treatment of established osteoporosis was as follows: PrM: etidronate (53%); PoM: bisphosphonates +/- HRT (53%). Ninety-six percent of CR used only bone mineral density (BMD) measurement to monitor therapy for corticosteroid induced osteoporosis. Most CR monitored BMD every 12 to 24 months for PrM (81%) and PoM (84%). The BMD parameter(s) (T and Z scores as measured by DEXA) used to initiate therapy for corticosteroid induced osteoporosis was variable. CONCLUSION: It appears that, while certain trends are evident, there is still considerable variability in the management of corticosteroid induced osteoporosis.     

鲑鱼降钙素鼻喷剂治疗绝经后骨质疏松患者骨密度及骨转换指标的变化

目的 观察鼻喷鲑鱼降钙素(calcitonin)治疗绝经后骨质疏松症(postmenopausal osteoporosis,PMO)患者6个月和12个月后骨密度及骨转换指标的变化.方法 选择PMO患者共67例,给予鼻喷降钙素治疗37例;其余30例PMO患者单纯服用钙剂和维生素D作为对照组.各组分别于用药前和用药后6个月和12个月采用DEXA骨密度仪测定骨密度;定量夹心酶联免疫法(ELISA)测定Ⅰ型胶原N末端肽(NTX)、骨特异性碱性磷酸酶(BALP)、抗酒石酸酸性磷酸酶(TRACP-5b)、25-羟维生素D,化学发光法测定骨钙素(BGP).结果 5例患者因医疗费用、拒绝坚持治疗退出试验,鼻喷降钙素组共32例完成试验.鼻喷降钙素治疗6个月后可见患者股骨颈和腰椎骨密度均较前有所增加,但仅在腰椎差异有统计学意义(P＜0.05),而在股骨颈治疗前后骨密度的差异无统计学意义(P＞0.05).治疗12个月时股骨颈和腰椎骨密度较前均明显升高,差异有统计学意义(P＜0.05).对照组在治疗6个月时的腰椎和治疗12个月时的股骨颈和腰椎部位骨密度均较治疗前降低,差异有统计学意义(P＜0.05).鼻喷降钙素治疗6个月和12个月时,股骨颈和腰椎骨密度均较对照组升高(P＜0.05).鼻喷降钙素治疗6个月后,TRACP-5b、NTX/Cr较治疗前降低,差异有统计学意义(P＜0.05);治疗12个月后,除TRACP-5b、NTX/Cr较前降低更加明显以外(P＜0.01),BALP较治疗前有升高,差异有统计学意义(P＜0.05).对照组在治疗12个月时,BALP较前有降低,差异有统计学意义(P＜0.05).25-羟维生素D在各组经治疗后,均明显升高,差异有统计学意义.结论 本研究结果显示鼻喷降钙素治疗6个月有效,12个月效果显著,可预防骨丢失,增加骨量.

Abstract：

Objective To study the changes of bone mineral density(BMD)and bone turnover in postmenopausal osteoporotic patients treated with salmon calcitonin nasal spray. Methods Sixty-seven postmenopausal osteoporotic patients were enrolled in our trial. All of them received calcium and vitamin D; 37patients were treated with salmon calcitonin nasal spray for 12 months and the other 30 patients received calcium and vitamin D only. Dual-energy X-ray absorptiometry(DEXA)and measurements of a series of bone turnover indices were performed before and after medication for 6 and 12 months. Results After treatment with salmon calcitonin nasal spray for6 months, BMD in lumbar spine 2-4 increased but no change occurred in femoral neck. However, after treatment for 12 months, BMD in both lumbar spine 2-4 and femoral neck increased. In the control group, BMD in lumbar spine 2-4 decreased after treatment for 6 and 12 months, but BMD in femoral neck decreased only after 12months. Comparing with the control group, after treatment with salmon calcitonin nasal spray, BMD in lumbar spine 2-4 and femoral neck were increased obviously. The level of TRACP-5b and NTX/Cr decreased after treatment with salmon calcitonin nasal spray for6 months and 12 months, while BALP increased only after treatment for 12 months. In the control group, BALP decreased after treatment for 12 months. The level of 25-(OH)vitamin D increased after treatment for 6 months and 12 months in both groups. Conclusions Long-term treatment with salmon calcitonin nasal spray prevents bone loss and may increase bone mass.     

Calcium,vitamin D and etidronate for the prevention and treatment of corticosteroid-induced osteoporosis in patients with rheumatic diseases

INTRODUCTION: Long-term glucocorticoid therapy, a major risk factor for the development of osteoporosis, is often necessary in chronically ill patients. At present there are no generally accepted guidelines for the prevention or treatment of steroid-induced osteoporosis. METHODS: In an open prospective study we investigated 99 patients with chronic rheumatic diseases receiving > or = 5 mg/day of prednisolone or the equivalent for at least one year. The objective was to identify osteoporosis risk factors in addition to glucocorticoid therapy and to evaluate the efficacy of prevention with calcium/vitamin D (group 1--patients with osteopenia) and treatment with cyclical etidronate (group 2--patients with osteoporosis). Biochemical markers of bone turnover, clinical parameters and bone mineral density (BMD) were measured. RESULTS: Increasing age and postmenopausal status were associated with more advanced manifestations of steroid-induced osteoporosis (p < 0.05). One year after the start of therapy parameters of bone metabolism increased significantly in group 1, while BMD did not change. In group 2, lumbar spine BMD increased significantly (p < 0.05) whereas femoral neck BMD and bone metabolism parameters remained constant. The intensity of back pain decreased in both groups (p < 0.05). There were fewer new fractures in group 2 than in group 1. CONCLUSION: Treatment with etidronate is effective in patients with glucocorticoid-induced osteoporosis.     

Bone mineral density in thyroxine treated females with or without a previous history of thyrotoxicosis

OBJECTIVE The results of studies examining the influence of T4 therapy upon bone mineral density (BMD) are conflicting. This conflict may, in part, reflect Inclusion of patients with varying thyroid disorders. We have therefore examined the influence of preceding thyroid history and T4 therapy on BMD. DESIGN Case-control studies of patients on long-term T4 therapy who have or have not previously received radio-iodine treatment for thyrotoxicosis, as well as previously thyrotoxic patients who have not required T4 replacement. PATIENTS Twenty-seven premenopausal and 60 post-menopausal females with a past history of thyrotoxicosis and subsequent T4 treated hypothyroidism (group l), 39 post-menopausal females with a past history of radio-iodine treated thyrotoxicosis not receiving T4 (group 2) and 22 post-menopausal females with primary hypothyroidism on T4 (group 3). Female controls individually matched to patients by age and menopausal status. MEASUREMENTS BMD measured by dual-energy X-ray absorptiometry. Serum biochemistry and tests of thyroid function. RESULTS No significant differences were found in femoral or lumbar spine BMD measurements between premenopausal patients and controls in group 1 or between group 2 patients and controls. Measurements of BMD at all sites were lower in post-menopausal patients in groups 1 and 2 than in controls; when allowance was made for differences In BMD due to body mass index by analysis of variance, significant reductions in femoral trochanter BMD (3·9%, P <0·05) and lumbar spine (5·6–8·5%, P <0·01) BMD results were found in post-menopausal females In group 1 and reductions in femoral trochanter (3·9%, P <0·01), Ward's triangle (5·6%, P <0·05) and lumbar spine (8·5%, P <0·01) BMD results in group 2. Separate analysis of BMD results of those with normal or reduced serum TSH did not affect outcome. BMD measurements were not significantly correlated with duration of T4 therapy, T4 dose, or serum free T4 or TSH in any patient group. CONCLUSIONS Thyroxine therapy alone does not represent a significant risk factor for loss of bone mineral density but there is a risk of bone loss in post-menopausal (but not premenopausal) females with a previous history of thyrotoxicosis treated with radioiodine.     

Effects of calcium supplementation on bone loss and fractures in congestive heart failure

BACKGROUND: Cross-sectional studies have shown that more than 50% of patients with congestive heart failure (CHF) have decreased bone mineral density (BMD). There is limited knowledge about the longitudinal changes of BMD and how to treat bone loss in patients with CHF. METHODS: The present study was a prospective, longitudinal trial in which 33 male patients with CHF (ejection fraction (EF): 30+/-11%) were assigned to 1000 mg calcium supplementation or no supplementation. BMD was measured at the lumbar spine (LS) and the femoral neck (FN) by dual-energy X-ray absorptiometry at baseline and after 12 months. RESULTS: Osteopenia (LS 33% and FN 36%) and osteoporosis (LS 15% and FN 6%) were frequently seen in these patients; 70% showed impaired renal function, 42% secondary hyperparathyroidism, and 33% hypogonadism. Bone resorption markers were strongly elevated and correlated negatively with the EF. Patients without calcium supplementation revealed a reduction of BMD (LS 1.7% and FN 1.9%) within 12 months. The fracture incidence was 6%. Patients with calcium supplementation also demonstrated a 6% fracture incidence and a decrease in BMD (LS 1.2% and FN 1.6%), which was not significantly different from the untreated group. Loss of BMD at FN was only seen in patients with impaired renal function. CONCLUSIONS: Patients with CHF demonstrate a progressive decrease in BMD when compared with age-matched healthy individuals. Increased bone resorption due to renal insufficiency with consecutive secondary hyperparathyroidism is a main reason for BMD loss in CHF. Calcium supplementation alone cannot sufficiently prevent the decrease in BMD.     

Effects of neridronate treatment in elderly women with osteoporosis

Osteoporosis is a common disorder, especially among elderly post-menopausal women. Elderly women are often affected by co-morbidities, impaired gastrointestinal function and reduced mobility; therefore, the treatment strategy for their osteoporosis can be difficult. In this randomized pilot study, we have investigated the effects of a 12-month treatment with neridronate on bone mineral density (BMD), bone turnover markers and quality of life (QoL). The study included 40 women (age, 65-80 yr; post-menopausal period, >15yr) from a single osteoporosis centre. Twenty women received a monthly im injection of 25 mg of neridronate associated with a daily dose of 500 mg of calcium and 400 U of vitamin D. Twenty women received calcium plus vitamin D supplements alone. Changes in BMD at the lumbar spine and femoral neck were measured by dual energy X-ray absorptiometry. Serum type I collagen C-telopeptide (sCTX), urinary free-deoxypyridinoline (ufDPD), bone alkaline phosphatase (ALP) and serum osteocalcin levels were determined. For the QoL assessment, the Italian version of the SF-36 test was administrated. Spine and hip BMD rose by 6.6 +/- 3 and 4.2 +/- 2.3%, respectively (p < 0.05), after 12 months of neridronate treatment. Markers of skeletal turnover significantly fell already after 3 months of neridronate treatment and decreased progressively thereafter within 12 months. The mean decrease at 12 months ranged from 38 +/- 11% for sCTX to 25.2 +/- 15% for ufDPD (p < 0.001, all). The mean improvement in QoL in the treated group was 45.7% for bodily pain, 37.5% for general health perception, 23.1% for vitality, 18% for emotional role functioning and 12% for physical role functioning. The changes observed in BMD, turnover markers and QoL in the untreated group were ns. The intermittent neridronate administration was easily manageable and well tolerated. In conclusion, neridronate currently represents a valid option for the treatment of osteoporosis, since it helps just as much as oral BPs in the improvement of BMD and in particular conditions it can be even more effective.     

Clinical experience with etidronate in osteoporosis

Summary Clinical experience with cyclical etidronate for the treatment of osteoporosis was reviewed in 69 consecutive patients. Six patients stopped treatment either due to adverse effects (5) or the decision to take hormone replacement therapy (HRT) (1). Bone mineral density (BMD) measurements using dual energy X-ray absorptiometry (DXA) were obtained in 63 patients (33 with spinal osteoporotic fractures and 30 with osteopenia) before and 1 year after treatment. BMD increased by an average of 4.50% (p<0.001) in the lumbar spine (range +14% to –12%) and 5.5% (p<0.01) at Ward's triangle (range +31% to –13%) while there was no significant change at the femoral neck (range +11% to –12%) and greater trochanter (range +12% to –15%). Significant rises in BMD were found at the lumbar spine and Ward's triangle in both osteoporotic and osteopenic groups. Of patients analysed after 1 year, 83% had an increased bone mass at the lumbar spine and 55% at the femoral neck.We conclude that there is a whide variation in the bone mass response to cyclical etidronate therapy, and in a minority of patients bone mass does not increase. For the majority of osteoporotic patients, however, we confirm the efficacy and tolerability of cyclical etidronate for the preservation of bone mass over 1 year in a clinical setting.     

Intravenous pamidronate in combination with calcium and vitamin D: highly effective in the treatment of low bone mineral density in inflammatory bowel disease

OBJECTIVE: Decreased bone mineral density (BMD) is common in inflammatory bowel disease (IBD) and an increased risk of fractures has been reported. Guidelines state bisphosphonate treatment for IBD patients with decreased BMD, but orally available bisphosphonates have been associated with gastrointestinal side effects and the absorption is poor. We investigated whether intravenous pamidronate is a safe and effective treatment. MATERIAL AND METHODS: Forty-nine IBD patients with decreased BMD as assessed by DEXA scan were treated with calcium 1000 mg and vitamin D 400 IU daily. In addition, 30 mg of pamidronate was administered intravenously every 3 months. DEXA scanning was performed prior to treatment, after 6 months and after 1 year. RESULTS: Of 49 IBD patients, 40 were osteoporotic and 9 were osteopenic. Twenty-six patients were female (mean age 40.8) and 23 were male (mean age 43.3). Treatment was discontinued in one patient because of fever after infusion. Otherwise, tolerability was excellent, and no adverse events were documented. A mean 0.51 increase of lumbar spine (L1-L4) T-scores was observed (CI 95% 0.35-0.67; p<0.0004). The effect of treatment on left femoral neck T-scores was less pronounced: 0.39 (CI 95% 0.24-0.53; p<0.0004). CONCLUSIONS: We conclude that intravenous pamidronate in combination with calcium and vitamin D is a well tolerated strategy for treating Crohn's disease associated osteopenia and osteoporosis. Although uncontrolled, treatment results in a significant increase of BMD in the lumbar spine.     

Comparative screening for thyroid disorders in old age in areas of iodine deficiency, long-term iodine prophylaxis and abundant iodine intake

OBJECTIVE The bisphosphonates have proven efficacy in the management of post-menopausal osteoporosis. However, the benefits of prolonged (<2 years) administration and the effects of discontinuation of bisphosphonate treatment are not clear. DESIGN We have previously reported a 2-year, randomized, double-blind, placebo-controlled trial of pamidronate therapy (150mg/day) in women with established post-menopausal osteoporosis. We now report the bone mineral density (BMD) changes in those women who continued for a third year of active treatment and were then observed off therapy for a further 12 months. PATIENTS Twenty-two women (mean age 66 years) continued on pamidronate in year 3, and in 16 of these the effects of subsequent discontinuation of therapy for 12 months were studied. MEASUREMENTS BMD was measured in the total body, lumbar spine and proximal femur using a Lunar DPX-L dual-energy, X-ray absorptiometer. RESULTS The third year of therapy with pamidronate was associated with a significant further gain in BMD only at the lumbar spine (2.1±0.8%, P=0.003), resulting in a total gain of 9.5±1.0% at that site over 3 years of treatment. In the total body, BMD tended to decline (?0.6±0.3%) in year 3. One year after discontinuation of pamidronate, there were significant losses of BMD in the total body (?1.9±0.3%, P<0.0001) and femoral trochanter (?2.7±0.9%, P=0.01), and non-significant changes at the lumbar spine (?0.9±0.8%), femoral neck (?0.5±1.6%), and Ward's triangle (?2.9±3.7%). By the end of one year off therapy, BMD was greater than baseline only in the lumbar spine (71±1.1%, P<0.0001) and femoral trochanter (4.5±1.88%, P<0.03). In the total body, BMD was 0.3±0.7% below the values at the trial’s inception (P=0.7). CONCLUSIONS These data demonstrate that the rate of bone gain associated with bisphosphonate use slows over time, and that significant bone loss follows withdrawal of these agents. These findings have important implications for the duration of use of these novel drugs in the therapy of osteoporosis and suggest a need for close observation following their discontinuation.     

The prevention of bone mineral loss with hormonal replacement therapy in premenopausal women on dialysis with estrogen deficiency

In 25-30% of premenopausal dialysis women low serum estrogen concentrations are observed. This "premature menopause" can significantly contribute to accelerated bone loss. The aim of the study was to evaluate the effect of estrogen-gestagen replacement therapy on bone mineral density (BMD) in hemodialysis women with secondary to uremia estrogen deficiency. Among 20 hemodialysis women, aged 18-45 years, with serum 17 beta-estradiol < 30 pg/ml, ten (group I) received transdermal estradiol with cyclic addition of noretisterone acetate (Estracomb TTS 50/0.25), and another ten formed the control group (group II). BMD was evaluated by dual photon x-ray absorptiometry (DEXA, Lunar) in: lumbar spine (L2-L4), 1/3 distal radius and femoral neck, before and after the study. Serum 17 beta-estradiol concentrations were measured before, and after 1, 3, 6 and 12 months of the study. After one year, in group I, in which serum 17 beta-estradiol normalized already during the first month (p < 0.001), an increase of in BMD was noted, although significant only in L2-L4 (p < 0.05). In group II, no change in serum 17 beta-estradiol and mild but insignificant decrease in BMD were observed. However, a comparison of BMD values after 12 months in both groups revealed the marked differences in all studied sites (p < 0.01, p < 0.02, p < 0.05 in L4-L2, distal radius and femoral neck, respectively). The mean serum calcium, phosphate, PTH and alkaline phosphatase activity were similar in both groups and did not change during the study. In premenopausal hemodialysis women with estrogen deficiency, hormonal replacement therapy inhibits bone demineralization and can be useful in prevention of early osteoporosis.     

The clinical benefits to bone mineral density were shown by cyclical oral etidronate administration in steroid induced osteoporosis]

PURPOSE: To compare the bone-mass effects of intermittent cyclic etidronate administration in patients of various rheumatic disease patients with corticosteroid-induced osteoporosis. PATIENTS AND METHODS: We evaluated bone mineral density (BMD) of lumbar spine in 34 female patients (mean age: 46.4 +/- 13.7 y. o. 17-71) treated with long term corticosteroid (> 6 months). Eighteen patients cyclically received etidronate orally (400 mg or 200 mg etidronate daily for 2 weeks, followed by 10-12 weeks drug-free periods). Twelve in these 18 patients received 400 mg (group A) and another 6 patients were treated with 200 mg/day (group B). Sixteen patients free from etidronate administrations were analysed as a control group. RESULTS: Cyclical etidronate therapy showed significant increase in BMD. The BMD of lumbar spine increased from 0.760 +/- 0.10 g/cm 2 to 0.783 +/- 0.11 g/cm 2 (%change from baseline 2.91 +/- 2.56%/year) in group A treated patients after 12 months. Reduced BMD (%change from baseline 1.55 +/- 2.48%) was observed in 16 control group patients (P < 0.0012). The BMD in group A was significantly high compared to group B or control after the etidronate treatment. In 7 of group A, BMD increased significantly on 6 months but no more significant increase was shown on 12 months compared to the value on 6 months. On the other hand the BMD tend to increased for after 2 years in intermittent cyclic etidronate treatment in 8 cases of group A. There were no adverse effects and abnormal laboratory data related to the administration of etidronate. Although only 2 cases of group A showed the findings of compression fracture before the study, but no new compression fracture appeared in any group during this study. CONCLUSION: It was shown that cyclical etidronate therapy is effective for steroid induced osteoporosis.     

Zoledronic acid prevents bone loss after allogeneic haemopoietic stem cell transplantation

Allogeneic haemopoietic stem cell transplant (alloHSCT) patients are at increased risk of osteoporosis. Zoledronic acid (ZA) is a potent i.v. bisphosphonate; however, there are few data on ZA use after alloHSCT. The aim of this study is to examine the effect of a single 4 mg ZA infusion in alloHSCT patients with either osteoporosis (T-score < -2.5) or rapid bone loss post-alloHSCT. An uncontrolled, prospective study of 12 consecutive patients receiving ZA, predominantly within the first year post-HSCT. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the spine and proximal femur pretransplant, pre-ZA and post-ZA. The median annualized percentage change in total hip BMD between the pretransplant scan and the scan immediately before ZA was -13% (range, -51 to +3.6%). After ZA treatment, the total hip BMD increased by a median of +3.3% (range, -20.4 to +14.8%) in 75% of patients. The median annualized percentage change in femoral neck BMD between the pretransplant scan and the scan immediately before ZA was -13.2% (range, -40 to +1.0%). Post-ZA, femoral neck BMD increased by a median of +1.4% (range, -22.2 to +33.6%). Only one patient continued to lose bone from the femoral neck post-ZA infusion. The median annualized percentage change in spinal BMD pretransplant was -12.5% (range, -38 to +6.9%). Post-ZA, spinal BMD decreased by a median of -2.8% (range, -27.6 to +24.4%). Four patients continued to lose bone from the spine post-ZA. ZA reduces bone loss in most patients after alloHSCT. Our data require confirmation in a larger prospective, randomized study.     

Effects of previous antiresorptive therapy on the bone mineral density response to two years of teriparatide treatment in postmenopausal women with osteoporosis

INTRODUCTION: EUROFORS was a 2-yr prospective, randomized trial of postmenopausal women with established osteoporosis, designed to investigate various sequential treatments after teriparatide 20 microg/d for 1 yr. The present secondary analysis examined the effects of 2 yr of open-label teriparatide in women previously treated with antiresorptive drugs for at least 1 yr. METHODS: A subgroup of 245 women with osteoporosis who had 2 yr of teriparatide treatment were stratified by previous predominant antiresorptive treatment into four groups: alendronate (n=107), risedronate (n=59), etidronate (n=30), and non-bisphosphonate (n=49). Bone mineral density (BMD) at the lumbar spine and hip was determined after 6, 12, 18, and 24 months, and bone formation markers were measured after 1 and 6 months. RESULTS: Significant increases in bone formation markers occurred in all groups after 1 month of teriparatide treatment. Lumbar spine BMD increased at all visits, whereas a transient decrease in hip BMD, which was subsequently reversed, was observed in all groups. BMD responses were similar in all previous antiresorptive groups. Previous etidronate users showed a higher increase at the spine but not at the hip BMD. Duration of previous antiresorptive therapy and lag time between stopping previous therapy and starting teriparatide did not affect the BMD response at any skeletal site. Treatment-emergent adverse events were similar to those reported in treatment-naive postmenopausal women with osteoporosis treated with teriparatide. CONCLUSIONS: Teriparatide induces positive effects on BMD and markers of bone formation in postmenopausal women with established osteoporosis, regardless of previous long-term exposure to antiresorptive therapies.     

The role of quantitative ultrasound in predicting osteoporosis defined by dual X-ray absorptiometry

The aim of this study was to establish whether quantitative ultrasound (QUS) parameters could identify patients classified as osteoporotic and osteopenic on the basis of dual energy X-ray absorptiometry (DEXA). One hundred and twenty-three patients (39 male, 84 female) with osteoporosis and suspected of having osteoporosis were included in this study. Broadband ultrasound attenuation (BUA) and speed of sound (SOS) were measured and bone mineral densities (BMD) of the lumbar spine and left hip was measured by DEXA. Subjects were classified into three groups (normal, osteopenic and osteoporotic) on the basis of BMD T-scores measured by DEXA. QUS parameters of the osteoporotic group were significantly lower than those of osteopenic and normal groups; there was no difference in QUS parameters between the normal and osteopenic groups. Correlations of both right and left SOS and BUA with the spine and femoral neck BMD were moderate (r = 0.343-0.539, P < 0.001). There was also reasonable correlation between DEXA and QUS T-scores (r = 0.364-0.510, P < 0.001). QUS had a sensitivity of 21% and a specificity of 95% for diagnosing osteoporosis. We concluded that, although DEXA and QUS parameters were significantly correlated, QUS parameters can not predict osteopenia as defined by DEXA, and sensitivities and specificities of QUS parameters were not sufficiently high for QUS to be used as an alternative to DEXA.