Osteoporosis needs aggressive screening and treatment

[Guest guest]

Rheumawire

May 25, 2004

Osteoporosis needs aggressive screening and treatment

Cleveland, OH - " In 2004, osteoporosis clearly qualifies for screening

as a societal health problem of enormous and increasing magnitude, "

begins a hard-hitting editorial in the May 24, 2004 issue of Archives of

Internal Medicine [1]. Accompanying several papers about osteoporosis in

the same issue, the editorial is a call to arms.

Osteoporosis clearly merits aggressive screening and treatment, but it

remains underrecognized and undertreated. It's time to take

responsibility, and that responsibility begins with any specialist whose

practice includes postmenopausal women and elderly patients. " The status

quo of 'missed opportunities' is unacceptable, " writes Dr Mazanec

(Cleveland Clinic Foundation, OH). " The buck stops with us. "

" The most significant barrier to osteoporotic fracture risk reduction is

failure of primary- and specialty-care physicians to implement screening

in appropriate populations, " comments the editorial. But there remain

some issues with the screening process itself, in particular over how

high the bar is set.

At present, the threshold for initiating treatment is often set at a

level of bone-mineral density (BMD) that indicates osteoporosis (T score

of -2.5 or less), but there is an argument for setting this bar lower,

at BMD levels that indicate osteopenia (T scores from -1.0 to -2.49).

These are based on definitions set by the World Health Organization. In

the US, the National Osteoporosis Foundation (NOF) sets the threshold a

bit lower, recommending treatment for women with a T score of -2.0 and

for those with a T score of -1.5 or less and at least 1 risk factor.

The argument against the higher threshold is that it misses many

candidates for treatment, a point clearly illustrated in 1 of the papers

published in the same issue [2], from a group led by Dr Ethel Siris

(Columbia-Presbyterian Medical Center, New York, NY). Using data on 149

524 white postmenopausal women from the National Osteoporosis Risk

Assessment (NORA) study, the researchers calculate that screening based

on the higher threshold of BMD levels indicating osteoporosis (T scores

of -2.5 or less) would have missed 82% of women who actually experienced

a new fracture in the next year.

" We conclude that substantial reductions in the population burden of

osteoporotic fractures experienced by postmenopausal women cannot be

accomplished simply by aggressively treating women with T scores of -2.5

or less, " the team concludes. " Future research is required to develop

strategies to risk-stratify women with osteopenia (T scores -2.5

to -0.1), who are at substantial risk for fracture and who constitute

most of those who sustain fractures. "

" There will have to be a targeted effort toward better identification

and treatment of women with moderate levels of low bone mass, who are

nonetheless at an increased risk for future fractures, " Siris et al

write. They comment that the NOF treatment intervention guidelines

provide a " reasonable strategy for targeting and treating women at high

risk of fractures. "

A related paper [3] homes in specifically on osteopenia and offers a

classification tool that accurately identifies postmenopausal women with

T scores of -2.5 to -1.0 who are at an increased risk of fracture within

12 months. This work also used data from the NORA study and is reported

by many of the same researchers, but this time led by Dr

(Colorado Center for Bone Research and University of Colorado, Denver).

Their analysis involved 57 421 postmenopausal white women with baseline

peripheral T scores between -2.5 and -1.0. Over the following year, 1130

of these women (2%) reported an incident clinical osteoporotic fracture

(196 at the hip, 126 vertebral, 319 rib, and 535 wrist or forearm).

The researchers then analyzed 32 risk factors to build an algorithm that

best predicted future fracture rates. They found the best predictors

were:

History of previous fracture.

A T score at a peripheral site of -1.8 or less.

Self-related poor health status.

Poor mobility.

Use of this algorithm would have correctly identified 74% of the women

who experienced a fracture, et al report.

Although the tool still needs validation in a separate cohort, et

al suggest that this NORA-based algorithm provides clinicians with " a

valuable and practical tool " for identifying a group of women with

osteopenia who are at increased short-term risk of new osteoporotic

fractureswomen for whom interventions to reduce risk should be

considered, they add.

A third paper in the same issue [4] illustrates the importance of

exercise in preventing bone loss in early postmenopausal women. German

researchers report 2-year results from the Erlangen Fitness Osteoporosis

Prevention Study (EFOPS).

This exercise program involved specific aerobic jumping and

muscle-strength sequences to maintain bone mass at the spine and

proximal femurthe most important osteoporotic fracture sites, the

researchers explain. Women had 2 to 4 sessions per week, and to maintain

long-term training compliance, high-impact sessions were alternated with

recreational periods.

The 2-year results are based on an analysis of 83 postmenopausal women

(mean age 55 years), of whom 50 were in the exercise group and 33 in the

control group. Over the 2 years, the control group showed significant

decreases in BMD at both the spine (-2.3%) and femoral neck (-2.9%), in

contrast to the exercise group, which showed a relatively large increase

(+3.1%) in BMD at the spine and a small but insignificant decrease (<1%)

at the femoral head. However, in the forearm, women in both groups

showed a decrease in BMD (by up to 4%). The researchers comment that

they are not altogether clear as to why, as exercises for the forearm

were included in the program and the exercise group showed increased

muscle strength in the arms.

The exercise group also showed significant decreases in levels of total

cholesterol (-5%) and triglycerides (-14%)both risk factors for coronary

heart diseasewhile the control group showed increases in both parameters

(4% and 23% respectively). In addition, they reported significantly less

back pain (both intensity and frequency) than did women in the control

group.

" General-purpose exercise programs with special emphasis on bone density

can significantly improve strength and endurance and reduce bone loss,

back pain, and lipid levels in osteopenic women in their critical early

postmenopausal years, " the researchers conclude.

Zosia Chustecka

Sources

1. Mazanec D. Osteoporosis screening; time to take responsibility. Arch

Intern Med 2004; 164:1047-1048.

2. Siris ES, Chen YT, Abbott TA, et al. Bone mineral density thresholds

for pharmacological intervention to prevent fractures. Arch Intern Med

2004; 164:1108-1112.

3. PD, Barlas S, Brenneman SK, et al. An approach to identifying

osteopenic women at increased short-term risk of fracture. Arch Intern

Med 2004; 164:1113-1120.

4. Kemmler W, Lauber D, Weineck J, et al. Benefits of 2 years of intense

exercise on bone density, physical fitness, and blood lipids in early

postmenopausal osteopenic women. Arch Intern Med 2004; 164:1084-1091.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org

[Guest guest]

I have wondered whether you fellow members of the list are screened for

osteoporosis, especially the ones on longtime steroid therapy. I know

that many of you are quite young and would not normally be given bone

density tests. So I wonder if your rheumies are concerned about

osteoporosis and orders bone density tests for you.

I had my first bone density test in 2000 and was told my bones were

normal. Two years later, after getting RA and being on prednisone for

several months, I had another one that showed that I had osteopenia, a

forerunner of osteoporosis. The rheumy Fellow that I was seeing at the

time hemmed and hawed about prescribing Evista, so I just got another

of my doctors to prescribe it.

I recently had another bone density test that shows that I still have

osteopenia in my lumbar spine. I have been taking Evista and 1200mg of

calcium with vitamin D. I can't really tell if it's helped any or not,

because the results are presented in a completely different way. I'm

hoping that my PCP can enlighten me when I go for a Pap test soon.

I would be interested in knowing the experiences of the rest of you.

Sue

On Sunday, June 6, 2004, at 01:52 PM, wrote:

> Rheumawire

> May 25, 2004

>

> Osteoporosis needs aggressive screening and treatment

>

> Cleveland, OH - " In 2004, osteoporosis clearly qualifies for screening

> as a societal health problem of enormous and increasing magnitude, "

> begins a hard-hitting editorial in the May 24, 2004 issue of Archives

> of

> Internal Medicine [1]. Accompanying several papers about osteoporosis

> in

> the same issue, the editorial is a call to arms.

[Guest guest]

I was given a bone density test because of the long term steroid

(prednisone) therapy for my lungs. It came back positive for osteopenia

in the hips and osterporosis in the tibia? Neck??. Something like that,

I'd have to look again to be sure but I know it was something neck. That

was about 3 months ago.

Rick

www.whosyomama.com

Re: [ ] Osteoporosis needs aggressive screening and

treatment

I have wondered whether you fellow members of the list are screened for

osteoporosis, especially the ones on longtime steroid therapy. I know

that many of you are quite young and would not normally be given bone

density tests. So I wonder if your rheumies are concerned about

osteoporosis and orders bone density tests for you.

I had my first bone density test in 2000 and was told my bones were

normal. Two years later, after getting RA and being on prednisone for

several months, I had another one that showed that I had osteopenia, a

forerunner of osteoporosis. The rheumy Fellow that I was seeing at the

time hemmed and hawed about prescribing Evista, so I just got another

of my doctors to prescribe it.

I recently had another bone density test that shows that I still have

osteopenia in my lumbar spine. I have been taking Evista and 1200mg of

calcium with vitamin D. I can't really tell if it's helped any or not,

because the results are presented in a completely different way. I'm

hoping that my PCP can enlighten me when I go for a Pap test soon.

I would be interested in knowing the experiences of the rest of you.

Sue

On Sunday, June 6, 2004, at 01:52 PM, wrote:

> Rheumawire

> May 25, 2004

>

> Osteoporosis needs aggressive screening and treatment

>

> Cleveland, OH - " In 2004, osteoporosis clearly qualifies for screening

> as a societal health problem of enormous and increasing magnitude, "

> begins a hard-hitting editorial in the May 24, 2004 issue of Archives

> of

> Internal Medicine [1]. Accompanying several papers about osteoporosis

> in

> the same issue, the editorial is a call to arms.

[Guest guest]

Sue,

I had my first bone density test 3 years ago and it showed osteopenia. I

have never been on steroids except for a dose pack to help with a severe

case of poison ivy a few years ago. I was prescribed fosamax, which I took

for one year. The bone density test was repeated after being on it for a

year again with no change in spite of the fosamax. I wasn¹t happy with what

I read about fosamax and I stopped taking it without my doctor¹s knowledge

(bad bad girl). I had another bone density test done a year after

discontinuing the fosamax and again no change. I¹m not sure what to think,

but for me I feel it is better to eat a bone friendly diet and do OP

exercises. RA itself is linked to OP so I¹m not sure if steroid use is

completely to blame, although I know it makes it much worse. OP also has

genetic elements, but my mom has great bone density. We attribute that to

many years of square dancing.

a

> I have wondered whether you fellow members of the list are screened for

> osteoporosis, especially the ones on longtime steroid therapy. I know

> that many of you are quite young and would not normally be given bone

> density tests. So I wonder if your rheumies are concerned about

> osteoporosis and orders bone density tests for you.

>

> I had my first bone density test in 2000 and was told my bones were

> normal. Two years later, after getting RA and being on prednisone for

> several months, I had another one that showed that I had osteopenia, a

> forerunner of osteoporosis. The rheumy Fellow that I was seeing at the

> time hemmed and hawed about prescribing Evista, so I just got another

> of my doctors to prescribe it.

>

> I recently had another bone density test that shows that I still have

> osteopenia in my lumbar spine. I have been taking Evista and 1200mg of

> calcium with vitamin D. I can't really tell if it's helped any or not,

> because the results are presented in a completely different way. I'm

> hoping that my PCP can enlighten me when I go for a Pap test soon.

>

> I would be interested in knowing the experiences of the rest of you.

>

> Sue

>

> On Sunday, June 6, 2004, at 01:52 PM, wrote:

>

>> > Rheumawire

>> > May 25, 2004

>> >

>> > Osteoporosis needs aggressive screening and treatment

>> >

>> > Cleveland, OH - " In 2004, osteoporosis clearly qualifies for screening

>> > as a societal health problem of enormous and increasing magnitude, "

>> > begins a hard-hitting editorial in the May 24, 2004 issue of Archives

>> > of

>> > Internal Medicine [1]. Accompanying several papers about osteoporosis

>> > in

>> > the same issue, the editorial is a call to arms.

>

>

>

>

[Guest guest]

In a message dated 07/06/2004 23:57:01 Central Standard Time,

rhow176@... writes:

> tibia? Neck??.

your tibia is in your lower leg. Neck is cervical.