EXTENSIVE EXPERTISE IN ENDOCRINOLOGY: Osteoporosis management

Abstract

Fractures occur in about half of older white women, and almost a third of older white men. However, 80% of the older individuals who have fractures do not meet the bone density definition of osteoporosis, suggesting that this definition is not an appropriate threshold for offering treatment. Fracture risk can be estimated based on clinical risk factors with or without bone density. A combination of calculated risk, fracture history, and bone density is used in treatment decisions. Medications available for reducing fracture risk act either to inhibit bone resorption or to promote bone formation. Romosozumab is unique in that it has both activities. Bisphosphonates are the most widely used interventions because of their efficacy, safety and low cost. Continuous use of oral bisphosphonates for >5 years increases the risk of atypical femoral fractures, so is usually punctuated with drug holidays of 6-24 months. Denosumab is a further potent antiresorptive agent given as six-monthly subcutaneous injections. It is comparable to the bisphosphonates in efficacy and safety but has a rapid offset of effect after discontinuation so must be followed by an alternative drug, usually a bisphosphonate. Teriparatide stimulates both bone formation and resorption, substantially increases spine density and reduces vertebral and non-vertebral fracture rates, though data for hip fractures are scant. Treatment is usually limited to 18-24 months, followed by transition to an anti-resorptive. Romosozumab is given as monthly subcutaneous injections for one year, followed by an anti-resorptive. This sequence prevents more fractures than anti-resorptive therapy alone. Because of cost, anabolic drugs are usually reserved for those at very high fracture risk. 25-hydroxyvitamin D levels should be maintained above 30 nmol/L, using supplements if sunlight exposure is limited. Calcium intake has little effect on bone density and fracture risk but should be maintained above 500 mg/day using dietary sources.

Application of neural network and nomogram for the prediction of risk factors for bone mineral density abnormalities: A cross-sectional NHANES-based survey

“…Although osteoporosis and osteopenia greatly increase bone fragility [ 13 ], they do not cause any evident symptoms in the early stage; therefore, they are not diagnosed until complications such as spinal or limb fractures occur [ 14 ], which seriously affect patients' health condition and quality of life, necessitating the importance of timely diagnosis and treatment of osteoporosis and osteopenia in the early stage [ 15 ]. Many studies have applied algorithms and evaluation tools based on public awareness of osteoporosis and osteopenia risk factors such as age, sex, family history of patients’ fractures, use of glucocorticoids and vitamin D, blood calcium, and other indicators [ 16 ] such as fracture risk assessment tool in the clinical setting [ 17 , 18 ], which indeed provides a reference to assess the risk of bone mineral density abnormalities in a certain population [ 19 ], but the evidence is not comprehensive. Taking the American population as an example, this study included the intake of carbohydrates, dietary fiber, coffee, and other dietary components, as well as the levels of electrolytes such as blood phosphorus, blood potassium, and blood sodium, which may be deficient in abnormalities, as research factors; next, the neural network and nomogram were integrated to establish a prediction model to provide a reference for people who are accustomed to consuming carbohydrates, dietary fiber, coffee, and other dietary components.…”

Osteoporosis: Spotlight on current approaches to pharmacological treatment

“…[ 15 ] Anabolic agents are recommended in only patients with a very high risk of fracture, due to high drug costs. [ 9 , 16 - 19 ] Low calcium intake and vitamin D deficiency are positively associated with the OP prevalence. [ 20 ] The use of dietary calcium and vitamin D alone in the treatment of OP is insufficient, and vitamin D and calcium deficiency should be corrected before pharmacological treatment.…”

“…The antiresorptive effects of DMAB rapidly decreases after treatment discontinuation. [ 19 ] If the treatment is interrupted, switching to a different anti-OP drug class, such as bisphosphonates, may be helpful to prevent complete loss of BMD gained with DMAB and maintain its anti-fracture efficacy. [ 9 , 48 ] After discontinuation of DMAB (7 months after the last injection), the risk of multiple vertebral fractures increases as a result of rapid rebound in bone turnover.…”

“…[ 9 , 48 ] After discontinuation of DMAB (7 months after the last injection), the risk of multiple vertebral fractures increases as a result of rapid rebound in bone turnover. [ 19 , 48 , 52 ] In most cases, patients have other risk factors for fracture such as previous vertebral fracture, low spine BMD, glucocorticoid use or aromatase inhibitor treatment; therefore, DMAB should not be stopped. [ 17 , 52 ]…”

Role of metabolic equivalent between calcium intake and vertebral fractures: a cross-sectional study of NHANES 2013–2014

“…Vertebral fractures are a common type of fracture in people over 50 years old, they tended to occur in postmenopausal women and are associated with osteoporosis [1,2]. Vertebral fractures can lead to acute and chronic pain, height loss, kyphosis, impaired activities of daily living, psychological distress, decreased quality of life, and reduced life expectancy [3][4][5].…”