Review of guidelines for testing and treatment of osteoporosis

Our knowledge on diagnosis and treatment of osteoporosis has steadily increased during the past decade. Several guidelines on treatment of osteoporosis are now available. Although there is heterogeneity in these recommendations, there are several common suggestions found. Case finding is advocated in all; however, it is generally acknowledged that further research is necessary to evaluate the effectiveness of case-finding strategies. Dual-energy x-ray absorptiometry is considered the gold standard for diagnosis of osteoporosis. The use of the T score is different for diagnostic purposes and for treatment decisions. Other bone measurement techniques are proposed as risk evaluation or as alternatives when dual-energy x-ray absorptiometry is not available. Bone markers are not considered for evaluation in clinical practice. Treatment options include general measures on lifestyle, fall prevention, calcium and vitamin D supplements, hormone therapy, raloxifene, and bisphosphonates. Consistent recommendations are found mostly for raloxifene in the prevention of vertebral fractures and for alendronate and risedronate in the prevention of vertebral and nonvertebral fractures, including hip fractures.     

Improving clinical decisions for women at risk of osteoporosis: dual-femur bone mineral density testing

CONTEXT: In bone mineral density (BMD) testing, unilateral hip analysis and lumbar spine measurement have been the clinical standard for diagnosis and treatment classification for postmenopausal women at risk of osteoporosis. OBJECTIVE: To determine if analysis of the bilateral hip in BMD testing has a clinical effect on diagnosis of osteoporosis and treatment classification of patients. METHODS: Dual-femur BMD test results from 313 postmenopausal women (mean age 61.2 years, range 32-90 years) were evaluated using standard BMD reference values for diagnosis and treatment classification. The author compared T scores for right and left femurs at three sites: femoral neck, trochanter, and total femur. Results: When the bilateral hip was considered in BMD testing and compared with unilateral hip results, a clinical change in diagnosis from normal to osteopenia occurred in 5.7% of subjects. In addition, a clinical change in diagnosis from osteopenia to osteoporosis occurred in 3.3% of subjects. A clinical change in treatment classification from "no treatment required" to "treatment required if one or more risk factors are present" occurred in 3% of subjects. A change in treatment classification from "treatment required if one or more risk factors are present" to "treatment required independent of risk factors" happened in 2.4% of subjects. CONCLUSION: When compared with BMD testing of the unilateral hip, inclusion of the bilateral hip in BMD testing resulted in a change in classification to a more severe diagnosis in a total of 9% of subjects, and to a more aggressive treatment category in a total of 5.4% of subjects. Dual-femur BMD testing may improve diagnosis and treatment classification for postmenopausal women at risk of osteoporosis.     

The validity of decision rules for selecting women with primary osteoporosis for bone mineral density testing

The purpose of this study was to determine the validity of the Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Self-Assessment Tool (OST) chart and equation, and a criterion based on body weight for identifying women with asymptomatic primary osteoporosis. Prospective recruitment and chart abstractions from family practices of three University affiliated hospitals were completed for women aged 45 years or more with baseline bone mineral density (BMD) testing results by dual energy X-ray absorptiometry. Those taking bone active medication other than hormone therapy, with prior fragility fracture or with risk factors for secondary osteoporosis were excluded. Women were categorized as being normal, osteopenic or osteoporotic by lowest BMD T-score at either the femoral neck or lumbar spine (L1–L4). Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve to identify those with osteoporosis were determined for each decision rule. The positive predictive value (PPV) for detecting osteoporosis after using a second cut point to convert each decision rule into a risk index (low, moderate or high risk) was also determined. The sensitivity of the decision rules to identify women with osteoporosis ranged from 92% to 95% and specificity from 35% to 46%. The area under the ROC curves were significantly better for the ORAI (0.80), OST chart (0.82) and OST equation (0.82) compared with the body weight criterion (0.73). PPV for detecting osteoporosis ranged from 30% to 58% among women deemed at high risk. These data confirm the validity of the ORAI, the OST chart and the OST equation as screening tools for BMD testing. Further evidence is required to confirm the validity of the body weight criterion.     

Influence of fracture history and bone mineral density testing on the treatment of osteoporosis in two non-academic community centers

A history of fracture and a low bone mineral density (BMD) are the strongest predictors of future osteoporotic fracture. This prospective cohort study assessed the impact of these two factors on treatment patterns in women undergoing their first BMD testing in a non-academic community setting. Successive women seen for first BMD testing at two testing centers completed a baseline questionnaire and a mailed 3-month follow-up questionnaire. Patients were grouped by history of fracture after age 20 years (present, absent) and by BMD result [osteoporosis (OP), osteopenia (OPN), normal BMD]. Thirty percent of 1144 patients at least 45 years old reported a history of fracture after age 20 years. They were no more likely than those without a history of fracture to be taking calcium (52% of total), vitamin D (31%), estrogen (31%), or a bisphosphonate (2%) before BMD testing. The BMD testing revealed OP in 20%, OPN in 45%, and normal BMD in 35%. Three months later, the percentages of patients taking treatments differed as follows: calcium (66 vs 53% in OP and OPN groups vs normal BMD), vitamin D (46 vs 37% in OPN group vs normal BMD), estrogen (25 vs 36 vs 44% in groups with OP, OPN, and normal BMD), a bisphosphonate (43 vs 11 vs 1%), and at least one of estrogen or a bisphosphonate (58 vs 43 vs 46%). Treatment decisions were influenced by first BMD testing but not significantly by a history of fracture. There is a substantial care gap in the treatment of patients with OP: either bisphosphonate or estrogen therapy was taken by only 31% of patients at least 45 years old and with a history of fracture after age 20 years before BMD testing and by only 58% of these and who also had OP by BMD.     

骨胶原与骨质疏松骨密度及骨生物力学的相关性研究

目的探讨骨胶原含量在绝经后骨质疏松症的发生、发展及在骨质疏松性骨折中的作用。方法取7个月龄未交配雌性SD大鼠60只，随机分为四组，A组：对照组（sham组）；B组：切除卵巢组；C组：切除卵巢＋雌激素治疗组；D组：切除卵巢＋降钙素治疗组。除A组外，其他三组通过切除双侧卵巢法12周后制成骨质疏松模型，24周后分别行k的力学特性、右侧股骨三点弯曲试验、羟脯氨酸含量、k骨密度（BMD）测定，Masson三色染色法显示骨胶原形态。结果A、C、D组与B组在k羟脯氨酸含量、BMD、k压缩力学参数值、右侧股骨生物力学参数值、骨胶原染色含量及形态方面差异均有统计学意义（P〈0．05），而A、C、D组之间差异无统计学意义（P〉0．05）。统计学分析显示羟脯氨酸含量与BMD及骨生物力学参数值呈直线相关性。结论骨质疏松的发生与骨胶原含量下降有关。骨胶原含量的下降与BMD降低及骨生物力学改变呈相关性。应用雌激素和降钙素治疗去势后骨质疏松大鼠，不仅可以提高其BMD含量和骨生物力学性能，而且还可以提高骨胶原的含量。     

绝经后骨质疏松及骨量减少患者治疗前后骨密度变化的研究

目的 观察利塞膦酸钠防治绝经后骨质疏松症的疗效。方法 绝经后骨质疏松症48例,对照组24例,服安慰剂,实验组24例,服利塞膦酸钠5 mg/d,两组每日均服凯思立D 1片,2组共观察6月。结果 利塞膦酸钠组腰椎、股骨颈及大粗隆的骨密度均明显升高(P<0.05),实验组总有效率为80.95％,明显高于对照组的45.45％(P<0.01)。结论 利塞膦酸钠能明显提高绝经后骨质疏松症患者的骨密度,副作用轻。     

骨质疏松症骨代谢生化指标与骨密度测量分析

目的为使骨质疏松症的治疗更加个体化，更具针对性。希望在骨代谢水平上对骨质疏松症患者进行深一步的分型，并能指导临床用药。方法观察住院和门诊骨质疏松症患者65例，空腹采血测骨钙素(BGP)、骨碱磷酶(B—ALP)、Ⅰ-型胶原C-末端(CTX)。骨密度(BMD)用美国NOLAND双能X线骨密度仪测定；应用积水潭医院软件分析，BMD≤-2．0SD诊断为骨质疏松症，排除继发性骨质疏松症。正常对照组选用健康体检者27例，检查项目同骨质疏松疗组。结果骨质疏松症患者各部位BMD明显低于正常组，血BGP明显比正常对照组升高，CTX，B—ALP与正常组无明显差别。而骨质疏松症患者血生化指标中，仅B—ALP与股骨颈和Ward三角区的BMD密切相关，CTX、BGP与各部位BMD无明显相关性。70岁以上患者B—ALP与股骨颈和Ward三角区BMD呈负相关；其中男患者CTX与股骨颈和大转子BMD呈正相关，B—ALP与Ward三角区BMD呈正相关；女性BMDB—ALP与Ward三角区BMD呈负相关。CTX仅在正常组与Ward三角区BMD相关。结论虽然骨代谢生化指标是用于评估骨转换率有效的方法，与BMD测定相结合能全面合理评价骨转换，有利于骨质疏松症的个体化治疗；但在骨质疏松症BMD和正常人之间血清中各项骨代谢生化指标有很多重叠，无法用这些指标来做骨质疏松症的诊断和分型，仅可用作治疗结果观察。     

骨密度测量技术诊断骨质疏松的评价

骨矿密度(BMD)是诊断骨量减少(低骨量,骨质疏松),评价骨丢失率和疗效的重要客观指标。被世界卫生组织(WHO)用来定义骨质疏松(OP)的诊断标准。目前非创伤性骨密度测量方法主要有以下几种:X线光密度法(RA),单光子吸收法(SPA),双光子吸收法(DPA),双能x线吸收测定(DEXA),定量CT(QCT)。不同的测量方法的优、缺点和临床意义不同,在此简要综述几种BMD测量方法和特点。     

绝经后骨质疏松症患者骨密度及骨代谢参数的调查研究

目的 了解E2和IL－6在骨质疏松症发病中的作用。方法 选择绝经后妇女120例，绝经后有骨质疏松60例（OP组），绝经后无骨质疏松60例（NOP组），另外选择绝经前妇女60例为对照组。对180名妇女雌二醇（E2）、骨密度（BMD）、白细胞介素－6（IL－6）、血清总碱性磷酸酶（ALP）、骨钙素（BGP）、尿羟脯氨酸肌酐比值（尿Hoc/Cr)、尿钙肌酐比值（尿Ca/Cr)等指标进行了测定。结果 绝经后妇女骨形成指标BGP及ALT明显高于对照组妇女，其中ALP在OP组和NOP组间有差异，而BGP在OP组和NOP组间无差异；绝经后妇女骨吸收指标尿HOP／Cr及尿Ca/Cr明显高于对照组妇女，OP组尿HOP／Cr及尿Ca/Cr又明显高于NOP组；绝经后妇女的血清E2的含量明显低于对照组（绝经前妇女），OP组又明显低于NOP组；绝经后妇女血清IL－6的含量明显高于对照组妇女，而OP组又明显高于NOP组。结论 本研究证明E2、IL－6与骨质疏松关系密切，雌激素水平的下降，IL－6分泌增多，是导致骨吸收加速的重要原因之一。     

Effect of alendronate on bone mineral density and bone turnover in Thai postmenopausal osteoporosis

Alendronate has recently been approved for the prevention and treatment of postmenopausal osteoporosis, and its efficacy has been demonstrated in many Western countries. Our present study was performed to evaluate the effect of alendronate on bone mineral density (BMD) and its tolerability in Thais. Eighty postmenopausal women with osteoporosis participated in this study. After giving informed consent, the subjects were randomly allocated either 10mg alendronate or placebo in a double-blind fashion. All patients received a supplement of 500mg elemental calcium daily. BMD at the lumbar spine, femoral neck, and distal forearm was measured at baseline and 6 and 12 months after treatment. Biochemical markers of bone resorption were determined at baseline and 6 months after treatment. Baseline characteristics were similar in both alendronate- and placebo-treated groups. Ten subjects discontinued the study. Of 70 subjects, 32 received 10mg alendronate daily and the remaining subjects received placebo. At 1 year, BMD in the alendronate-treated group had increased from baseline by 9.2%, 4.6%, and 3.1% at lumbar spine, femoral neck, and distal forearm, respectively. These percentages were greater than those in controls (4.1%, 0.6%, and 1.0%, respectively). Urinary N-terminal telopeptide (NTx)-I and serum C-terminal telopeptide (CTx)-I levels decreased in both groups after 6 months of treatment. However, more reduction was demonstrated in the alendronate-treated group (71.9% vs. 28.4%, P 0.01, and 84.7% vs. 33.1%, P 0.01, respectively). Compliance with treatment and drug tolerability were good in both alendronate and placebo groups. We concluded that treatment with alendronate 10mg daily for Thai postmenopausal women with osteoporosis significantly increased BMD at all skeletal sites and reduced biochemical markers of bone resorption. It was well tolerated without any serious side effects.     

体积骨密度的估算方法及其对诊断骨质疏松的意义

骨密度（BMD）有面积骨密度（aBMD）和体积骨密度（vBMD）两种表达方式,它们在临床实验研究中被广泛采用。本文综述了vBMD的估算方法、aBMD和vBMD存在的性别差异和种族差异,以及aBMD和vBMD对诊断骨质疏松的影响。     

原发性骨质疏松症患者骨密度和骨代谢指标的对比研究

目的探讨骨密度（BMD）和骨代谢指标在原发性骨质疏松症的诊治过程中的临床意义.方法采用XR-36型双能X线骨密度仪和放射免疫方法,对252例中老年志愿者不同部位的BMD及血清骨钙素（BGP）、Ⅰ型前胶原氨基端前肽、Ⅰ型胶原交联羧基末端肽的含量进行测定.结果①无论是对照组还是骨质疏松组（OP）,老年男性BMD均明显高于老年女性BMD,其差异具有非常显著性（P＜0.01）;②OP组的BGP值明显低于对照组,其差异具有显著性（P＜0.05）;OP组的血清Ⅰ型前胶原氨基端前肽（PINP）值均明显低于对照组,而血清Ⅰ型胶原交联羧基末端肽（ICTP）值均明显高于对照组,其差异具有显著性（P＜0.05）.结论联合检测BGP、HNP和ICTP水平可直接反映骨胶原合成和降解状态,对于判断老年OP的进程以及指导OP的用药有着重要的意义.     

Changes in bone mineral density in transient osteoporosis of the hip

Transient osteoporosis of the hip is a disorder characterised by pain, and associated with temporary osteopaenia. Although osteopaenia is the essence of the condition, data do not exist about the local bone density of the femoral neck if no medication is administered. We describe three patients who were treated with limitation of weight-bearing only. Repeated bone mineral density measurements were obtained, and that at the femoral neck was lowest two months after the onset of the condition. The mean reduction in bone mineral density when compared with an age-matched control group was 13% (3% to 24%). Spontaneous recovery was observed in all patients.     

血清Chemerin水平与骨质疏松症患者骨密度的相关性研究

目的评估骨质疏松症患者和健康对照者血清chemerin水平,探讨血清chemerin水平与骨密度(bone mineral density,BMD)的关系。方法选取2017年1月至2018年2月在西宁市第二人民医院门诊就医的200名参与者,进行年龄和性别匹配的病例对照研究。Pearson相关性检验用于调查血清chemerin水平与BMD之间的关系。结果分为骨质疏松组100例,对照组100例。骨质疏松组患者血清chemerin水平[(87. 65±5. 57) ng/m L]显著高于对照组[(70. 09±5. 16) ng/m L],差异有统计学意义(P0. 01)。两组股骨骨密度与chemerin呈负相关(骨质疏松组:r=-0. 394,P0. 01;对照组:r=-0. 679,P0. 01);两组腰椎骨密度与chemerin也呈负相关(骨质疏松组:r=-0. 305,P0. 01;对照组r=-0. 361,P0. 01)。结论骨质疏松症患者血清chemerin水平升高,与BMD呈负相关。需进一步研究chemerin在骨质疏松症病理生理中的作用。     

Pelvic floor symptoms and bone mineral density in women undergoing osteoporosis evaluation

Introduction and hypothesis

Our aim was to characterize pelvic floor symptoms in postmenopausal women who had undergone osteoporosis evaluation and examine their association with bone mineral density (BMD).

Methods

Pelvic floor symptom questionnaires were mailed to 4,026 women. Multivariate logistic regression models controlling for age, race, body mass index (BMI), and chronic obstructive pulmonary disease (COPD) were performed comparing symptoms in women with osteoporosis (T score ≤ ?2.5) and osteopenia (T score > ?2.5 to < ?1) at any site to women with normal BMD (T score: ≥ ?1, referent).

Results

There were 1,774/4,026 (44 %) questionnaires returned; 1,655 were included in the analysis (362 osteoporosis, 870 osteopenia, 423 normal BMD). Overall prevalence of any urinary incontinence (UI) was 1,226/1,640 (75 %), with UI ≥2–3 times/week in 699/1,197 (58 %), fecal incontinence over the past month in 247/1,549 (16 %), and prolapse in 162/1,582 (10 %). Multivariate analyses revealed that women with osteopenia had increased risk of incontinence of solid stool [adjusted odds ratio (aOR) 1.7, 95 % confidence interval (CI) 1.1–2.4). Risk of UI ≥2–3 times/week was not increased in women with osteoporosis (aOR 0.9, CI 0.6–1.3) and was lower in women with osteopenia (aOR 0.7, CI 0.5–0.9). In women with osteoporosis, the odds of moderate- to large-volume urine loss versus small/none was higher for those in the lower T-score quartile (lower BMD; aOR 1.43, CI 1.1–1.9).

Conclusions

In women undergoing osteoporosis evaluation, those with osteopenia were at increased risk of fecal incontinence but not UI compared with normal women. Osteoporotic women with the lowest T scores had higher risk of moderate- to large-volume UI. It is unclear whether there is a pathophysiologic link between BMD loss and development of pelvic floor symptoms.     

Teriparatide increases bone mineral density in a man with osteoporosis pseudoglioma

Osteoporosis Pseudoglioma (OPPG) is characterized by severe juvenile-onset osteoporosis and ocular abnormalities. It is caused by one of several inactivating mutations in LRP5, a gene importantly involved in bone formation. The objective of this study was to evaluate the efficacy of teriparatide in a young man with OPPG. The subject of this case report is a 19-year-old man with congenital blindness and low trauma fractures because of OPPG. A 2-year course of teriparatide, 20 μg/day, was initiated after a 6-year course of intravenous pamidronate infusions, the latter 3 years of which had minimal effects on bone mineral density (BMD). Measurements in serum were made of C-terminal telopeptide of type I collagen (CTX), N-terminal propeptide of type I collagen (P1NP), total and ionized calcium, phosphate, uric acid, complete blood count, and renal and liver function tests. Urinary calcium/creatinine ratio was determined. BMD was measured by DXA yearly. BMD increased by 9.7% in lumbar spine and 10.2% in right femur hip. CTX rose early, peaking in month 3, followed by an increase in P1NP, peaking in month 9. Both indices returned to baseline by month 24. The increase in CTX followed by P1NP is an unusual time course when teriparatide is used to treat osteoporosis but may be typical of low bone turnover states. There were no adverse events. In a patient with OPPG, teriparatide markedly increased BMD in the lumbar spine and femur hip.     

Reference values of bone mineral density and prevalence of osteoporosis in Chinese adults

Summary

We pooled bone mineral density (BMD) data published in 91 articles including 139,912 Chinese adults and then established a national-wide BMD reference database at the lumbar spine and femur neck for Chinese adults. The prevalence of osteoporosis in the middle-aged and elderly Chinese population was also estimated.

Introduction

Well-accepted reference value of BMD is lacking in Chinese. We established the reference database and assessed osteoporosis prevalence based on published literature conducted in the Mainland China, Taiwan, and Hong Kong Chinese.

Methods

We searched for all published articles indexed in MEDLINE, PubMed, CNKI, and SinoMed up to January 2013. We included cross-sectional studies that examined BMD using a dual-energy X-ray absorptiometry at the femur neck (FN) and/or lumbar spine (LS) in healthy adults. Overall age-specific mean (SD) BMD were pooled after standardization.

Results

Ninety-one studies including 51,906 males and 88,006 females (≥20 years) in 38 cities in China were included in this pooling study. Gender- and age-specific reference curves of standardized BMD (sBMD) at the LS and FN were constructed. The sBMD cutoffs for osteoporosis classification were 0.746 and 0.549 in women, and 0.680 and 0.568 g/cm² in men; age-standardized prevalence of osteoporosis was 23.9 % and 12.5 % in women and 3.2 % and 5.3 % in men aged ≥50 years at the LS and FN, respectively. Meta-regression analysis showed that greater age and altitude, lower latitude, smaller city size, earlier detection time, and random sample were correlated to lower sBMD in at least one gender-specific bone sites; the Hologic DXA produced a higher value of FN sBMD than the other two devices (Lunar and Norland).

Conclusion

We have established a national-wide BMD reference database at the LS and FN for Chinese adults and estimated the prevalence of osteoporosis in the middle-aged and elderly Chinese population.     

Assessment of bone mineral density in postmenopausal and senile osteoporosis using quantitative CT

The authors analyzed bone mineral density in 213 patients from January 1988 to September 1989. Bone mineral density of the vertebral body in the osteoporosis group of patients was compared with that in the normal group to investigate the correlation between bone mineral density and age distribution, and to estimate fracture threshold in the osteoporosis group. It was found that men, by linear regression, lose an average of 0.91% of bone per year, and women, by cubic regression, lose an average of 1.14% per year, accelerating at menopause. In the osteoporotic group, bone mineral density of men decreased an average of 29.7% compared with the non-osteoporotic group; that of women decreased an average of 29.9%. There was no difference between sexes. The fracture threshold of the osteoporotic patient was estimated to be about 90 mg/cm3.