Lois E. Wehren

Osteoporosis and fracture risk in women of different ethnic groups.

Osteoporosis and 1‐year fracture risk were studied in 197,848 postmenopausal American women from five ethnic groups. Weight explained differences in BMD, except among blacks, who had the highest BMD. One SD decrease in BMD predicted a 50% increased fracture risk in each group. Despite similar relative risks, absolute fracture rates differed.

Gender differences in mortality after hip fracture: the role of infection.

Possible explanations for the observed gender difference in mortality after hip fracture were examined in a cohort of 804 men and women. Mortality during 2 years after fracture was identified from death certificates. Men were twice as likely as women to die, and deaths caused by pneumonia/influenza and septicemia showed the greatest increase.

Trabecular bone microarchitecture after alendronate treatment of osteoporotic women.

ABSTRACT Objective: To compare the microarchitecture of iliac crest trabecular bone from women treated for two to three years with alendronate versus that of women treated with placebo. Research design and methods: Three-dimensional micro-computed tomography (micro-CT; resolution 20 µm) and two-dimensional histomorphometry (resolution 5–7 µm) were used to examine trabecular bone from single transilial biopsies obtained at the completion of clinical trials. Main outcome measures: Microarchitectural variables, including bone volume, trabecular number, trabecular thickness, and trabecular spacing in specimens from alendronate- and placebo-treated women were examined. Three-dimensional images of trabecular bone from both groups were constructed from CT images. Correlations among variables and between techniques were also calculated. Results: Eighty-eight specimens were suitable for evaluation by both techniques. As measured by two-dimensional histomorphometry, bone volume fraction (as a proportion of total volume) and trabecular thickness were significantly greater in alendronate specimens, 17.1 ± 5.5% vs. 13.4 ± 5.5% ( p = 0.0043) and 127 ± 29 µm vs. 109 ± 28 µm ( p = 0.0090), respectively, and trabecular spacing was significantly smaller, 729 ± 227 µm vs. 862 ± 338 µm ( p = 0.005). Micro-CT yielded similar findings: bone volume and trabecular number were significantly greater in alendronate specimens: 19.4 ± 6.2% vs. 16.2 ± 6.3% ( p = 0.0412) and 1.46 ± 0.32 vs. 1.31 ± 0.33 per mm ( p = 0.0346). Two-dimensional and micro-CT measured characteristics correlated strongly with one another, with Pearson product moment correlation coefficients ranging from 0.60 (for trabecular thickness) to 0.83 (for bone volume). Conclusions: Trabecular microarchitecture of the ilium, whether studied by two- or three-dimensional methods, is better (greater bone volume, greater trabecular thickness, decreased trabecular spacing) after alendronate treatment than after two to three years of treatment with placebo. Bone volume in a trabecular region is strongly correlated to its microarchitecture, suggesting that bone quantity predicts values for these microarchitectural endpoints.

Recency and duration of postmenopausal hormone therapy : effects on bone mineral density and fracture risk in the National Osteoporosis Risk Assessment (NORA) study

ObjectivesResults from the Womens Health Initiative showed that postmenopausal hormone replacement therapy (HRT) prevents fractures but has an overall unfavorable risk:benefit ratio, leading to the recommendation that HRT be used only for women with troublesome menopause symptoms, and for as short a time as possible. This recommendation has important implications for the timing and duration of HRT and the prevention of osteoporosis. The large number of women participating in the National Osteoporosis Risk Assessment (NORA) program provided the opportunity to evaluate bone mineral density (BMD) and 1-year fracture risk in analyses stratified by duration and recency of HRT. DesignParticipants were 170,852 postmenopausal women aged 50 to 104, without known osteoporosis, who were recruited from primary physicians offices across the US. BMD was measured at one of four peripheral sites, and the 1-year risk of osteoporotic fracture was assessed by questionnaire. ResultsAt baseline, current HRT users had the highest T-scores at every age. Among current hormone users, women who had used HRT longest had the highest BMD levels. Women who had stopped HRT more than 5 years previously, regardless of duration of use, had T-scores similar to never-users. Current but not past hormone use at baseline was associated with a 25% to 29% lower risk of osteoporotic fracture (P < 0.0001) in 1 year, compared with nonusers. These findings were independent of age, ethnicity, body mass index, lifestyle, years postmenopausal, and site of BMD measurement. ConclusionsWe conclude that postmenopausal BMD and fracture are closely associated with current, but not prior, HRT use. Use of HRT for 5 years or less, as proposed for treatment of symptomatic women during menopause transition, is unlikely to preserve bone or significantly reduce fracture risk in later years.

How useful are measures of BMD and bone turnover

ABSTRACT Measurements of bone mineral density (BMD) and biochemical markers of bone turnover are useful in the diagnosis and management of osteoporosis, as well as in research relating to the pathogenesis and treatment of the disease. Recent challenges to the utility of these measures have resulted in some confusion among both researchers and clinicians. BMD accounts for the great majority of bone strength and is the current gold standard for the diagnosis of osteoporosis, as well as for prediction of fracture risk. Although bone turnover increases sharply after menopause, biochemical markers of bone turnover have limited usefulness in fracture risk prediction. Persistently elevated bone turnover throughout the menopause is associated with structural decrements, but these cannot be measured routinely and non-invasively. In research applications, both BMD and markers of bone turnover are used to identify candidate agents in preclinical and clinical studies. In addition, head-to-head comparisons of treatments utilize these measures, because fracture endpoint trials would need to be extraordinarily large and complex. Analyses that have suggested that change in BMD or bone turnover ‘explains’ little of change in fracture risk with treatment appear to be flawed. Although neither can perfectly predict fracture, they are our current best alternatives.

Putting evidence-based medicine into clinical practice: comparing anti-resorptive agents for the treatment of osteoporosis

SUMMARY Objective: To compare the effectiveness of anti-resorptive agents in reducing the risk of vertebral and non-vertebral fractures using data from published meta-analyses and the technique of adjusted indirect comparisons. Research design and methods: Pairs of agents were compared by adjusted indirect comparison of their effects relative to a common comparator (placebo) using meta-analyses published by The Osteoporosis Methodology Group and The Osteoporosis Research Advisory Group. Results: Adjusted indirect comparisons identified only one pair of agents that had significantly different effects on vertebral fracture incidence: alendronate was 34% more effective than calcitonin (Relative Risk: 0.66, 95% Confidence Interval: 0.48–0.90). Alendronate was significantly more effective than risedronate, calcitonin, estrogen, etidronate, and raloxifene (Relative Risks: 0.70 [0.49, 0.99], 0.64 [0.42, 0.98], 0.59 [0.41, 0.84], 0.52 [0.32, 0.82], and 0.56 [0.40, 0.78], respectively) in reducing the incidence of non-vertebral fractures. No other significant pairwise differences were observed. Conclusions: The results suggest that there are differences in anti-fracture efficacy among anti-resorptive agents, particularly for non-vertebral fractures. Direct head-to-head comparisons would be needed to confirm these findings but are unlikely to be conducted.

The epidemiology of osteoporosis and fractures in geriatric medicine

Several conclusions can be drawn from this article, the most important of which are as follows: 1. Low bone mass is widely prevalent among older men and women and is associated with important fracture consequences. 2. The prevalence of osteoporosis and fracture is projected to increase over the next several decades. 3. Although Caucasian women are at greatest risk, substantial numbers of men and women of non-Caucasian heritage are also affected. 4. The population burden of disease consequences, including mortality, morbidity, and social and personal cost, is anticipated to increase as well. 5. In the group at greatest risk (Caucasian women), osteoporosis and fracture have well-established risk factors, many of which are modifiable. 6. Relevance of these risk factors for groups other than Caucasian women appears likely but requires further investigation. 7. Personal and societal costs associated with osteoporosis are enormous; as such, identification of persons at risk and prevention and treatment of this disease should be public health priorities.

Reliability and Validity of the Self-efficacy and Outcome Expectations for Osteoporosis Medication Adherence Scales

Purpose The purpose of this study was to test the reliability and validity of the self-efficacy and outcome expectations for osteoporosis medication adherence measures (SEOMA and OEOMA). Design This was a descriptive study involving a single face-to-face interview. Sample The study included 152 older adults with a mean age of 85.7 (+) 5.5 years, the majority of whom were Caucasian (99%), female (74%), and unmarried (75%). Methods In addition to the SEOMA and OEOMA measures, demographic information (age, gender, and marital status) and other health behaviors (exercise and osteoporosis medication use) were explored. Results There was evidence of reliability of the SEOMA and OEOMA based on internal consistency and R2 values. Evidence of the validity of the SEOMA and OEOMA measures was based on confirmatory factor analysis and hypothesis testing. Conclusion This study is an important first step to developing reliable and valid measures of self-efficacy and outcome expectations for adherence to osteoporosis medications. Implications for nursing practice The SEOMA and OEOMA can be used to evaluate self-efficacy and outcome expectancy beliefs related to osteoporosis medication use in older adults and interventions developed to strengthen those beliefs and improve medication adherence.

Physician and patient perceptions on the use of vitamin D and calcium in osteoporosis treatment : a European and Latin American perspective

ABSTRACT Objective: Although osteoporosis treatment guidelines include recommendations for calcium and vitamin D intake, routine use of adequate supplementation often is low. This study explored the attitudes of physicians and patients towards vitamin D and calcium and patient use of both supplements. Methods: A survey of randomly selected physicians in the United Kingdom, Mexico, and Austria, and the first seven eligible women with osteoporosis from each of their practices, was conducted. Physicians were asked to rate the importance of vitamin D and calcium in osteoporosis management on a scale of 1 to 10 (1 = not important at all, 10 = extremely important) and to estimate use of calcium and vitamin D supplements by their patients. Patients were asked about their own use of vitamin D and calcium, and their perceptions regarding these supplements. Results: Altogether 151 physicians (50 in Austria, 51 in the UK, and 50 in Mexico), and 910 osteoporosis patients (350 in Austria, 212 in UK, and 348 in Mexico) completed telephone surveys. Approximately, 86%, 28%, and 46% of physicians rated importance of vitamin D and calcium as being 9 or 10 in Austria, UK, and Mexico, respectively. Overall, 50% of patients reported taking calcium and vitamin D supplements (47% of these on a daily basis and 46% on a regular basis), and 19% of patients reported that they had no discussions with their physicians about calcium, while 39% reported no discussion about vitamin D. Conclusions: Despite the recognition by physicians and patients that vitamin D and calcium are important for bone health, only a small proportion of patients regularly take supplements. This is the case even when vitamin D and calcium supplements are provided free with osteoporosis drug prescriptions, as occurs in Austria. However, these results rely on patient self-report of compliance which can lead to overestimation. In addition this studys participants may not be representative of other patient populations. This study provides additional evidence that compliance with treatment guidelines is suboptimal, and highlights the need for further study to explore the discrepancy between the highly perceived importance of vitamin D and calcium and the low use of both supplements, and to improve use among osteoporosis patients.

Skeletal consequences of hormone therapy discontinuance: a systematic review.

Although hormone therapy protects against bone loss after menopause, currently it is not recommended once menopausal symptoms have subsided. We reviewed randomized clinical trials to quantify bone loss after stopping hormone therapy and summarize treatment options for women who discontinue hormone treatment. We conducted a search of MEDLINE and EMBASE for randomized, controlled trials measuring bone mineral density (BMD) after hormone therapy discontinuation. Other known published and unpublished data were also included. Eleven studies fulfilled the search criteria. In each, bone loss was rapid after stopping hormone therapy, with BMD declines ranging from 2.3% to 6.2% in the first year. Increases in bone turnover markers also occurred rapidly when hormone therapy was stopped. Limited data addressing treatment after hormone therapy is stopped exist; only 2 studies specifically evaluated therapy to protect bone after hormone discontinuation. Taken together, these 2 studies demonstrate that alendronate produced significant increases relative to placebo in spine, hip, and total body BMD in women with low bone density who had discontinued hormone therapy within the past 3 months, preventing the rapid bone loss seen on discontinuation of hormone therapy. Among treatment options for preventing bone loss on discontinuation of hormone therapy for which randomized clinical trial data are available, alendronate prevented bone loss or increased bone density in postmenopausal women with low bone density. Women who are discontinuing hormone therapy should be counseled about potential bone loss and effective treatment options. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to state that discontinuation of replacement menopausal hormone therapy, which protects against bone loss, is not recommended after menopause symptoms have subsided; recall that it may accelerate bone loss; and explain that there is bone loss preventive treatment for women after discontinuation of hormone therapy.