Jeff Evans

MONTREAL — Performance measures for the evaluation and management of osteoporosis have already been developed and soon could be making their way into clinical practice. But clinicians across specialties will need to collaborate to implement the measures and make certain that patients do not miss screening when they have a fragility fracture or other risk factors, according to several experts.

“I think we all have a consensus there is a need to improve the standard of quality of care in our patients with osteoporosis and osteoporotic fracture,” said Dr. Stuart L. Silverman, professor of clinical medicine at the University of California, Los Angeles, one of several speakers on this topic at the annual meeting of the American Society for Bone and Mineral Research.

Strategies must start at the national level but also involve specialty and primary care medical societies, hospitals, individual clinicians, and public education. Now that osteoporosis performance measures have been developed by both the Joint Commission and an American Medical Association-led coalition of societies, specialty and primary care medical societies need to develop fracture treatment advocacy statements, Dr. Silverman said.

The Joint Commission's Measures

Evidence-based monographs such as the Joint Commission's “Improving and Measuring Osteoporosis Management” are produced by expert panels with the goal of providing voluntary measures to attain in managing a disease. They are not considered standards until field-testing has ensured that measures are valid and can be obtained. The publishing of such measures as standards can “make many people feel they should be followed,” said Dr. Ethel S. Siris, professor of clinical medicine at Columbia University, New York.

“I have argued for the past couple of years that one of the reasons that we have not been more successful in getting more people evaluated and treated is because as a young field, we don't yet have an established standard of care,” Dr. Siris said.

Standards that can be established as “core measures” for hospitals and emergency departments can then become a part of the accreditation process for a hospital. Home health agencies, long-term care facilities, rehabilitation centers, and subacute care facilities, such as skilled nursing facilities, may be required to fulfill a core measure, but other care delivery settings, such as ambulatory care at a doctor's office, would not be required to maintain the standards.

Field-testing of the Joint Commission's performance measures, which were published in January, will require $380,000 over 2 years “to be validated and ultimately published as recommended standards,” she said.

Society-Backed Measures

The American Medical Association's Physician Consortium for Performance Improvement (PCPI) partnered with the American Academy of Family Physicians, the American Academy of Orthopaedic Surgeons, the American Association of Clinical Endocrinologists, the American College of Rheumatology, the Endocrine Society, and the National Committee for Quality Assurance to approve six osteoporosis performance measures in 2006. Of the 6 measures, 5 are identical or similar to 5 of the 10 measures that have been proposed by the Joint Commission. (See box.)

The PCPI measures focus primarily on outpatient management, whereas the Joint Commission document includes inpatient measures, said Dr. Kenneth G. Saag of the University of Alabama at Birmingham.

Orthopedists' Perspective

Orthopedists “have a central role in the evaluation and management of patients who sustain fragility fractures. But the problem is that we don't really fulfill the role that we could,” said Dr. Joseph D. Zuckerman of the New York University Hospital for Joint Diseases, speaking on behalf of the American Academy of Orthopaedic Surgeons.

It has been tough to get orthopedists to “buy into” evaluating and managing fragility fracture patients for osteoporosis, said Dr. Zuckerman, who chaired the AAOS Council on Education from 1999 to 2005. “They just didn't accept it as an essential part of the practice of orthopedic surgery.”

Orthopedists have cited a lack of expertise, general interest, and available consultants, as well as concerns about malpractice liability and the viewpoint of it being a medical and not a surgical problem, he said.

“We are really in the best position to initiate screening and fracture treatments, but that can only be done in a context where we have a partner or partners to work with, whether it is a rheumatologist or a primary care physician with interest in this.”

Studies have shown how orthopedists can team with other clinicians in caring for these patients. In one study, an orthopedist's participation in a standardized protocol for ordering bone mineral density testing led to a BMD evaluation in 93% of patients and initiation of treatment in 74%. In comparison, the act of sending a letter to a primary care physician that advised him or her of guidelines for osteoporosis screening had almost no impact (J. Bone Joint Surg. Am. 2008;90:953–61).

Challenges Ahead

It is hoped “that there can be some blending or melding [of the two sets of performance measures] so that we can talk about similar outcomes or processes and numerators, and similar target populations,” Dr. Silverman said.

He added that he thought that because the “measures were based on referring to fracture only,” the target population of the measures may need to change, perhaps to those defined in the new National Osteoporosis Foundation (NOF) guidelines as having low bone mass and high risk on the World Health Organization Fracture Risk Assessment Tool (FRAX).

“Should we change the wording in some of these performance measures to include these target populations as well?” Dr. Silverman asked.

The implementation of the measures as standards faces potential problems because they are not mandatory and the financial incentives for reporting them may not be worth the cost and time that is required, Dr. Silverman said. Not only may the data be hard to locate across different electronic health record systems, but the lack of reimbursement to individual hospitals for diagnosis-related groups that have been assigned for treating and diagnosing a fracture may make the measures harder to implement. The NOF has raised only $60,000 of the $380,000 that will be required to validate the Joint Commission's measures, he added.

All of the speakers disclosed relationships with companies that manufacture osteoporosis medications, including speakers bureau, consulting fees, performing paid research, and/or being on an advisory committee or other paid committee.

Proposed Osteoporosis Performance Measures

Many measures proposed by the Joint Commission are similar to those suggested by the AMA's Physician Consortium for Performance Improvement (PCPI):

▸ Screening women at risk. How many women patients aged 60–64 years with one or more risk factors, and those older than 65 years, have had at least one central DXA exam?

PCPI measurement: What percentage of female patients aged 65 years and older have had a central DXA exam ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months?

▸ Secondary causes. For all patients with a new diagnosis of osteoporosis, how many have had an appropriate, minimal laboratory investigation ordered or performed prior to discharge within 3 months of the initial diagnosis?

PCPI measurement: What percentage of patients aged 18 years and older with one of the following conditions or therapies has had a central DXA ordered or performed or pharmacologic therapy prescribed within 12 months: use of oral glucocorticoid therapy for greater than 3 months; aromatase therapy for breast cancer; hypogonadism; fracture history; transplant history; obesity surgery; malabsorption disease?

▸ BMD testing of glucocorticoid patients. How many patients older than 18 years who have taken oral glucocorticoids for at least 3 months have had a DXA exam ordered or performed since the initiation of therapy?

▸ Dietary education. How many patients with a diagnosis of osteoporosis or their caregivers have received information about calcium and vitamin D within the past year?

PCPI measurement: What percentage of patients, regardless of age, with a diagnosis of osteoporosis have either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months?

▸ Osteoporosis activity counseling. How many patients have received documented, age-appropriate activity information or referral for activity counseling within 36 months?

▸ Pharmacotherapy. How many patients at least 50 years old with a diagnosis of osteoporosis have been provided with pharmacotherapy within the most recent 12 months?

PCPI measurement: What percentage of patients aged 50 years and older with a diagnosis of osteoporosis were prescribed pharmacologic therapy within 12 months?

▸ Risk assessment or treatment for osteoporosis after fracture in an acute care setting. What percentage of patients aged 50 years or older with new fracture in an emergency department or a mental hospital have received a central DXA exam or a prescription for pharmacotherapy for osteoporosis prevention or treatment? (This is a potential core measure that “would have teeth,” Dr. Siris said.)

PCPI measurement: In what percentage of patients aged 50 years and older treated for a hip, spine, or distal radial fracture is there documentation of communication with the physician managing the patient's ongoing care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis? (Dr. Saag noted that this is the only measure that differs from the Joint Commission's recommendations.)

▸ Risk assessment or treatment for osteoporosis after fracture in a nonacute care setting. What percentage of patients aged 50 years or older who have a documented history of a fracture within the past 3 months have received a central DXA exam or a prescription for pharmacotherapy for osteoporosis prevention or treatment?

PCPI measurement: What percentage of patients aged 50 years and older with a fracture of the hip, spine, or distal radius have had a central DXA exam ordered or performed or pharmacologic therapy prescribed?

▸ Smoking and alcohol counseling. How many patients with a diagnosis of osteoporosis or fracture have received counseling for excess alcohol consumption or smoking cessation? (This is a potential core measure.)

▸ Fall risk and personal safety education. How many patients aged 50 years or older with a new diagnosis of osteoporosis or fracture (or their caregivers) have received documented fall risk and safety education to minimize the risk of falls within 3 months of the event?

MONTREAL — Performance measures for the evaluation and management of osteoporosis have already been developed and soon could be making their way into clinical practice. But clinicians across specialties will need to collaborate to implement the measures and make certain that patients do not miss screening when they have a fragility fracture or other risk factors, according to several experts.

“I think we all have a consensus there is a need to improve the standard of quality of care in our patients with osteoporosis and osteoporotic fracture,” said Dr. Stuart L. Silverman, professor of clinical medicine at the University of California, Los Angeles, one of several speakers on this topic at the annual meeting of the American Society for Bone and Mineral Research.

Strategies must start at the national level but also involve specialty and primary care medical societies, hospitals, individual clinicians, and public education. Now that osteoporosis performance measures have been developed by both the Joint Commission and an American Medical Association-led coalition of societies, specialty and primary care medical societies need to develop fracture treatment advocacy statements, Dr. Silverman said.

The Joint Commission's Measures

Evidence-based monographs such as the Joint Commission's “Improving and Measuring Osteoporosis Management” are produced by expert panels with the goal of providing voluntary measures to attain in managing a disease. They are not considered standards until field-testing has ensured that measures are valid and can be obtained. The publishing of such measures as standards can “make many people feel they should be followed,” said Dr. Ethel S. Siris, professor of clinical medicine at Columbia University, New York.

“I have argued for the past couple of years that one of the reasons that we have not been more successful in getting more people evaluated and treated is because as a young field, we don't yet have an established standard of care,” Dr. Siris said.

Standards that can be established as “core measures” for hospitals and emergency departments can then become a part of the accreditation process for a hospital. Home health agencies, long-term care facilities, rehabilitation centers, and subacute care facilities, such as skilled nursing facilities, may be required to fulfill a core measure, but other care delivery settings, such as ambulatory care at a doctor's office, would not be required to maintain the standards.

Field-testing of the Joint Commission's performance measures, which were published in January, will require $380,000 over 2 years “to be validated and ultimately published as recommended standards,” she said.

Society-Backed Measures

The American Medical Association's Physician Consortium for Performance Improvement (PCPI) partnered with the American Academy of Family Physicians, the American Academy of Orthopaedic Surgeons, the American Association of Clinical Endocrinologists, the American College of Rheumatology, the Endocrine Society, and the National Committee for Quality Assurance to approve six osteoporosis performance measures in 2006. Of the 6 measures, 5 are identical or similar to 5 of the 10 measures that have been proposed by the Joint Commission. (See box.)

The PCPI measures focus primarily on outpatient management, whereas the Joint Commission document includes inpatient measures, said Dr. Kenneth G. Saag of the University of Alabama at Birmingham.

Orthopedists' Perspective

Orthopedists “have a central role in the evaluation and management of patients who sustain fragility fractures. But the problem is that we don't really fulfill the role that we could,” said Dr. Joseph D. Zuckerman of the New York University Hospital for Joint Diseases, speaking on behalf of the American Academy of Orthopaedic Surgeons.

It has been tough to get orthopedists to “buy into” evaluating and managing fragility fracture patients for osteoporosis, said Dr. Zuckerman, who chaired the AAOS Council on Education from 1999 to 2005. “They just didn't accept it as an essential part of the practice of orthopedic surgery.”

Orthopedists have cited a lack of expertise, general interest, and available consultants, as well as concerns about malpractice liability and the viewpoint of it being a medical and not a surgical problem, he said.

“We are really in the best position to initiate screening and fracture treatments, but that can only be done in a context where we have a partner or partners to work with, whether it is a rheumatologist or a primary care physician with interest in this.”

Studies have shown how orthopedists can team with other clinicians in caring for these patients. In one study, an orthopedist's participation in a standardized protocol for ordering bone mineral density testing led to a BMD evaluation in 93% of patients and initiation of treatment in 74%. In comparison, the act of sending a letter to a primary care physician that advised him or her of guidelines for osteoporosis screening had almost no impact (J. Bone Joint Surg. Am. 2008;90:953–61).

Challenges Ahead

It is hoped “that there can be some blending or melding [of the two sets of performance measures] so that we can talk about similar outcomes or processes and numerators, and similar target populations,” Dr. Silverman said.

He added that he thought that because the “measures were based on referring to fracture only,” the target population of the measures may need to change, perhaps to those defined in the new National Osteoporosis Foundation (NOF) guidelines as having low bone mass and high risk on the World Health Organization Fracture Risk Assessment Tool (FRAX).

“Should we change the wording in some of these performance measures to include these target populations as well?” Dr. Silverman asked.

The implementation of the measures as standards faces potential problems because they are not mandatory and the financial incentives for reporting them may not be worth the cost and time that is required, Dr. Silverman said. Not only may the data be hard to locate across different electronic health record systems, but the lack of reimbursement to individual hospitals for diagnosis-related groups that have been assigned for treating and diagnosing a fracture may make the measures harder to implement. The NOF has raised only $60,000 of the $380,000 that will be required to validate the Joint Commission's measures, he added.

All of the speakers disclosed relationships with companies that manufacture osteoporosis medications, including speakers bureau, consulting fees, performing paid research, and/or being on an advisory committee or other paid committee.

Proposed Osteoporosis Performance Measures

Many measures proposed by the Joint Commission are similar to those suggested by the AMA's Physician Consortium for Performance Improvement (PCPI):

▸ Screening women at risk. How many women patients aged 60–64 years with one or more risk factors, and those older than 65 years, have had at least one central DXA exam?

PCPI measurement: What percentage of female patients aged 65 years and older have had a central DXA exam ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months?

▸ Secondary causes. For all patients with a new diagnosis of osteoporosis, how many have had an appropriate, minimal laboratory investigation ordered or performed prior to discharge within 3 months of the initial diagnosis?

PCPI measurement: What percentage of patients aged 18 years and older with one of the following conditions or therapies has had a central DXA ordered or performed or pharmacologic therapy prescribed within 12 months: use of oral glucocorticoid therapy for greater than 3 months; aromatase therapy for breast cancer; hypogonadism; fracture history; transplant history; obesity surgery; malabsorption disease?

▸ BMD testing of glucocorticoid patients. How many patients older than 18 years who have taken oral glucocorticoids for at least 3 months have had a DXA exam ordered or performed since the initiation of therapy?

▸ Dietary education. How many patients with a diagnosis of osteoporosis or their caregivers have received information about calcium and vitamin D within the past year?

PCPI measurement: What percentage of patients, regardless of age, with a diagnosis of osteoporosis have either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months?

▸ Osteoporosis activity counseling. How many patients have received documented, age-appropriate activity information or referral for activity counseling within 36 months?

▸ Pharmacotherapy. How many patients at least 50 years old with a diagnosis of osteoporosis have been provided with pharmacotherapy within the most recent 12 months?

PCPI measurement: What percentage of patients aged 50 years and older with a diagnosis of osteoporosis were prescribed pharmacologic therapy within 12 months?

▸ Risk assessment or treatment for osteoporosis after fracture in an acute care setting. What percentage of patients aged 50 years or older with new fracture in an emergency department or a mental hospital have received a central DXA exam or a prescription for pharmacotherapy for osteoporosis prevention or treatment? (This is a potential core measure that “would have teeth,” Dr. Siris said.)

PCPI measurement: In what percentage of patients aged 50 years and older treated for a hip, spine, or distal radial fracture is there documentation of communication with the physician managing the patient's ongoing care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis? (Dr. Saag noted that this is the only measure that differs from the Joint Commission's recommendations.)

▸ Risk assessment or treatment for osteoporosis after fracture in a nonacute care setting. What percentage of patients aged 50 years or older who have a documented history of a fracture within the past 3 months have received a central DXA exam or a prescription for pharmacotherapy for osteoporosis prevention or treatment?

PCPI measurement: What percentage of patients aged 50 years and older with a fracture of the hip, spine, or distal radius have had a central DXA exam ordered or performed or pharmacologic therapy prescribed?

▸ Smoking and alcohol counseling. How many patients with a diagnosis of osteoporosis or fracture have received counseling for excess alcohol consumption or smoking cessation? (This is a potential core measure.)

▸ Fall risk and personal safety education. How many patients aged 50 years or older with a new diagnosis of osteoporosis or fracture (or their caregivers) have received documented fall risk and safety education to minimize the risk of falls within 3 months of the event?

MONTREAL — Performance measures for the evaluation and management of osteoporosis have already been developed and soon could be making their way into clinical practice. But clinicians across specialties will need to collaborate to implement the measures and make certain that patients do not miss screening when they have a fragility fracture or other risk factors, according to several experts.

“I think we all have a consensus there is a need to improve the standard of quality of care in our patients with osteoporosis and osteoporotic fracture,” said Dr. Stuart L. Silverman, professor of clinical medicine at the University of California, Los Angeles, one of several speakers on this topic at the annual meeting of the American Society for Bone and Mineral Research.

Strategies must start at the national level but also involve specialty and primary care medical societies, hospitals, individual clinicians, and public education. Now that osteoporosis performance measures have been developed by both the Joint Commission and an American Medical Association-led coalition of societies, specialty and primary care medical societies need to develop fracture treatment advocacy statements, Dr. Silverman said.

The Joint Commission's Measures

Evidence-based monographs such as the Joint Commission's “Improving and Measuring Osteoporosis Management” are produced by expert panels with the goal of providing voluntary measures to attain in managing a disease. They are not considered standards until field-testing has ensured that measures are valid and can be obtained. The publishing of such measures as standards can “make many people feel they should be followed,” said Dr. Ethel S. Siris, professor of clinical medicine at Columbia University, New York.

“I have argued for the past couple of years that one of the reasons that we have not been more successful in getting more people evaluated and treated is because as a young field, we don't yet have an established standard of care,” Dr. Siris said.

Standards that can be established as “core measures” for hospitals and emergency departments can then become a part of the accreditation process for a hospital. Home health agencies, long-term care facilities, rehabilitation centers, and subacute care facilities, such as skilled nursing facilities, may be required to fulfill a core measure, but other care delivery settings, such as ambulatory care at a doctor's office, would not be required to maintain the standards.

Field-testing of the Joint Commission's performance measures, which were published in January, will require $380,000 over 2 years “to be validated and ultimately published as recommended standards,” she said.

Society-Backed Measures

The American Medical Association's Physician Consortium for Performance Improvement (PCPI) partnered with the American Academy of Family Physicians, the American Academy of Orthopaedic Surgeons, the American Association of Clinical Endocrinologists, the American College of Rheumatology, the Endocrine Society, and the National Committee for Quality Assurance to approve six osteoporosis performance measures in 2006. Of the 6 measures, 5 are identical or similar to 5 of the 10 measures that have been proposed by the Joint Commission. (See box.)

The PCPI measures focus primarily on outpatient management, whereas the Joint Commission document includes inpatient measures, said Dr. Kenneth G. Saag of the University of Alabama at Birmingham.

Orthopedists' Perspective

Orthopedists “have a central role in the evaluation and management of patients who sustain fragility fractures. But the problem is that we don't really fulfill the role that we could,” said Dr. Joseph D. Zuckerman of the New York University Hospital for Joint Diseases, speaking on behalf of the American Academy of Orthopaedic Surgeons.

It has been tough to get orthopedists to “buy into” evaluating and managing fragility fracture patients for osteoporosis, said Dr. Zuckerman, who chaired the AAOS Council on Education from 1999 to 2005. “They just didn't accept it as an essential part of the practice of orthopedic surgery.”

Orthopedists have cited a lack of expertise, general interest, and available consultants, as well as concerns about malpractice liability and the viewpoint of it being a medical and not a surgical problem, he said.

“We are really in the best position to initiate screening and fracture treatments, but that can only be done in a context where we have a partner or partners to work with, whether it is a rheumatologist or a primary care physician with interest in this.”

Studies have shown how orthopedists can team with other clinicians in caring for these patients. In one study, an orthopedist's participation in a standardized protocol for ordering bone mineral density testing led to a BMD evaluation in 93% of patients and initiation of treatment in 74%. In comparison, the act of sending a letter to a primary care physician that advised him or her of guidelines for osteoporosis screening had almost no impact (J. Bone Joint Surg. Am. 2008;90:953–61).

Challenges Ahead

It is hoped “that there can be some blending or melding [of the two sets of performance measures] so that we can talk about similar outcomes or processes and numerators, and similar target populations,” Dr. Silverman said.

He added that he thought that because the “measures were based on referring to fracture only,” the target population of the measures may need to change, perhaps to those defined in the new National Osteoporosis Foundation (NOF) guidelines as having low bone mass and high risk on the World Health Organization Fracture Risk Assessment Tool (FRAX).

“Should we change the wording in some of these performance measures to include these target populations as well?” Dr. Silverman asked.

The implementation of the measures as standards faces potential problems because they are not mandatory and the financial incentives for reporting them may not be worth the cost and time that is required, Dr. Silverman said. Not only may the data be hard to locate across different electronic health record systems, but the lack of reimbursement to individual hospitals for diagnosis-related groups that have been assigned for treating and diagnosing a fracture may make the measures harder to implement. The NOF has raised only $60,000 of the $380,000 that will be required to validate the Joint Commission's measures, he added.

All of the speakers disclosed relationships with companies that manufacture osteoporosis medications, including speakers bureau, consulting fees, performing paid research, and/or being on an advisory committee or other paid committee.

Proposed Osteoporosis Performance Measures

Many measures proposed by the Joint Commission are similar to those suggested by the AMA's Physician Consortium for Performance Improvement (PCPI):

▸ Screening women at risk. How many women patients aged 60–64 years with one or more risk factors, and those older than 65 years, have had at least one central DXA exam?

PCPI measurement: What percentage of female patients aged 65 years and older have had a central DXA exam ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months?

▸ Secondary causes. For all patients with a new diagnosis of osteoporosis, how many have had an appropriate, minimal laboratory investigation ordered or performed prior to discharge within 3 months of the initial diagnosis?

PCPI measurement: What percentage of patients aged 18 years and older with one of the following conditions or therapies has had a central DXA ordered or performed or pharmacologic therapy prescribed within 12 months: use of oral glucocorticoid therapy for greater than 3 months; aromatase therapy for breast cancer; hypogonadism; fracture history; transplant history; obesity surgery; malabsorption disease?

▸ BMD testing of glucocorticoid patients. How many patients older than 18 years who have taken oral glucocorticoids for at least 3 months have had a DXA exam ordered or performed since the initiation of therapy?

▸ Dietary education. How many patients with a diagnosis of osteoporosis or their caregivers have received information about calcium and vitamin D within the past year?

PCPI measurement: What percentage of patients, regardless of age, with a diagnosis of osteoporosis have either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months?

▸ Osteoporosis activity counseling. How many patients have received documented, age-appropriate activity information or referral for activity counseling within 36 months?

▸ Pharmacotherapy. How many patients at least 50 years old with a diagnosis of osteoporosis have been provided with pharmacotherapy within the most recent 12 months?

PCPI measurement: What percentage of patients aged 50 years and older with a diagnosis of osteoporosis were prescribed pharmacologic therapy within 12 months?

▸ Risk assessment or treatment for osteoporosis after fracture in an acute care setting. What percentage of patients aged 50 years or older with new fracture in an emergency department or a mental hospital have received a central DXA exam or a prescription for pharmacotherapy for osteoporosis prevention or treatment? (This is a potential core measure that “would have teeth,” Dr. Siris said.)

PCPI measurement: In what percentage of patients aged 50 years and older treated for a hip, spine, or distal radial fracture is there documentation of communication with the physician managing the patient's ongoing care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis? (Dr. Saag noted that this is the only measure that differs from the Joint Commission's recommendations.)

▸ Risk assessment or treatment for osteoporosis after fracture in a nonacute care setting. What percentage of patients aged 50 years or older who have a documented history of a fracture within the past 3 months have received a central DXA exam or a prescription for pharmacotherapy for osteoporosis prevention or treatment?

PCPI measurement: What percentage of patients aged 50 years and older with a fracture of the hip, spine, or distal radius have had a central DXA exam ordered or performed or pharmacologic therapy prescribed?

▸ Smoking and alcohol counseling. How many patients with a diagnosis of osteoporosis or fracture have received counseling for excess alcohol consumption or smoking cessation? (This is a potential core measure.)

▸ Fall risk and personal safety education. How many patients aged 50 years or older with a new diagnosis of osteoporosis or fracture (or their caregivers) have received documented fall risk and safety education to minimize the risk of falls within 3 months of the event?

MONTREAL — The clinical risk factors of age and bone mineral density at the hip appear to predict the probability of a hip fracture or a major osteoporotic fracture significantly better than the World Health Organization's more complex Fracture Risk Assessment Tool, according to an analysis of data from a prospective study of 6,252 older white women.

The results suggest that “the addition of [complex] clinical risk factor information to age and BMD alone does not enhance the prediction of these fractures in older women,” said Dr. Kristine E. Ensrud, professor of medicine at the University of Minnesota, Minneapolis.

The FRAX algorithm is designed to predict only the 10-year probability of a hip fracture or a major osteoporotic fracture. It builds a risk profile based on nine clinical risk factors (age, sex, prior history of fracture, oral glucocorticoid use, presence of rheumatoid arthritis, parental history of hip fracture, smoking status, alcohol consumption, and body mass index).

Dr. Ensrud and her colleagues used data from 6,252 participants in the Study of Osteoporotic Fractures, which enrolled women during 1986–1988. Hip BMD measurements and all of the FRAX clinical risk factors were available for these women, who had an average age of 71 years. Incident fractures were confirmed in 98% of cases reported during the study's 10-year follow-up period.

A combination of age and hip BMD had significantly greater ability to predict the 10-year risk of a hip fracture than did the FRAX algorithm alone, based on area-under-the-curve (AUC) statistics that the investigators calculated from receiver operating characteristic curves that were built with data from the study. However, the AUC statistic that was derived from the age-plus-hip-BMD model (0.76) was similar to that obtained with FRAX plus hip BMD (0.75). The AUC statistic for FRAX alone was 0.71. (An AUC of 0.50 reflects a predictive ability equal to chance.)

Similarly, age plus hip BMD had a significantly greater ability to predict both major osteoporotic fractures (hip, clinical spine, wrist, or humerus) and clinical fractures (defined as nonvertebral or clinical vertebral fractures) than did the FRAX algorithm alone, Dr. Ensrud reported at the annual meeting of the American Society for Bone and Mineral Research.

To refine their analysis further, Dr. Ensrud and her associates compared the proportion of women across the models who were classified in the highest decile of fracture risk and who actually experienced a fracture outcome. This type of assessment enhances the clinical usefulness of a risk prediction model because it contains a higher proportion of women who actually experienced the outcome in question, she said.

This simple model of age and prior fracture history (rather than hip BMD) also predicted the 10-year risk of hip, osteoporotic, and clinical fractures just as well as the FRAX algorithm alone did. This finding suggests that “in a setting where BMD is not available, the addition of [complex] clinical risk factor information to age and prior fracture history alone does not enhance the prediction of these fractures in older women,” Dr. Ensrud said.

The study was funded by the National Institute on Aging.

MONTREAL — The clinical risk factors of age and bone mineral density at the hip appear to predict the probability of a hip fracture or a major osteoporotic fracture significantly better than the World Health Organization's more complex Fracture Risk Assessment Tool, according to an analysis of data from a prospective study of 6,252 older white women.

The results suggest that “the addition of [complex] clinical risk factor information to age and BMD alone does not enhance the prediction of these fractures in older women,” said Dr. Kristine E. Ensrud, professor of medicine at the University of Minnesota, Minneapolis.

The FRAX algorithm is designed to predict only the 10-year probability of a hip fracture or a major osteoporotic fracture. It builds a risk profile based on nine clinical risk factors (age, sex, prior history of fracture, oral glucocorticoid use, presence of rheumatoid arthritis, parental history of hip fracture, smoking status, alcohol consumption, and body mass index).

Dr. Ensrud and her colleagues used data from 6,252 participants in the Study of Osteoporotic Fractures, which enrolled women during 1986–1988. Hip BMD measurements and all of the FRAX clinical risk factors were available for these women, who had an average age of 71 years. Incident fractures were confirmed in 98% of cases reported during the study's 10-year follow-up period.

A combination of age and hip BMD had significantly greater ability to predict the 10-year risk of a hip fracture than did the FRAX algorithm alone, based on area-under-the-curve (AUC) statistics that the investigators calculated from receiver operating characteristic curves that were built with data from the study. However, the AUC statistic that was derived from the age-plus-hip-BMD model (0.76) was similar to that obtained with FRAX plus hip BMD (0.75). The AUC statistic for FRAX alone was 0.71. (An AUC of 0.50 reflects a predictive ability equal to chance.)

Similarly, age plus hip BMD had a significantly greater ability to predict both major osteoporotic fractures (hip, clinical spine, wrist, or humerus) and clinical fractures (defined as nonvertebral or clinical vertebral fractures) than did the FRAX algorithm alone, Dr. Ensrud reported at the annual meeting of the American Society for Bone and Mineral Research.

To refine their analysis further, Dr. Ensrud and her associates compared the proportion of women across the models who were classified in the highest decile of fracture risk and who actually experienced a fracture outcome. This type of assessment enhances the clinical usefulness of a risk prediction model because it contains a higher proportion of women who actually experienced the outcome in question, she said.

This simple model of age and prior fracture history (rather than hip BMD) also predicted the 10-year risk of hip, osteoporotic, and clinical fractures just as well as the FRAX algorithm alone did. This finding suggests that “in a setting where BMD is not available, the addition of [complex] clinical risk factor information to age and prior fracture history alone does not enhance the prediction of these fractures in older women,” Dr. Ensrud said.

The study was funded by the National Institute on Aging.

MONTREAL — The clinical risk factors of age and bone mineral density at the hip appear to predict the probability of a hip fracture or a major osteoporotic fracture significantly better than the World Health Organization's more complex Fracture Risk Assessment Tool, according to an analysis of data from a prospective study of 6,252 older white women.

The results suggest that “the addition of [complex] clinical risk factor information to age and BMD alone does not enhance the prediction of these fractures in older women,” said Dr. Kristine E. Ensrud, professor of medicine at the University of Minnesota, Minneapolis.

The FRAX algorithm is designed to predict only the 10-year probability of a hip fracture or a major osteoporotic fracture. It builds a risk profile based on nine clinical risk factors (age, sex, prior history of fracture, oral glucocorticoid use, presence of rheumatoid arthritis, parental history of hip fracture, smoking status, alcohol consumption, and body mass index).

Dr. Ensrud and her colleagues used data from 6,252 participants in the Study of Osteoporotic Fractures, which enrolled women during 1986–1988. Hip BMD measurements and all of the FRAX clinical risk factors were available for these women, who had an average age of 71 years. Incident fractures were confirmed in 98% of cases reported during the study's 10-year follow-up period.

A combination of age and hip BMD had significantly greater ability to predict the 10-year risk of a hip fracture than did the FRAX algorithm alone, based on area-under-the-curve (AUC) statistics that the investigators calculated from receiver operating characteristic curves that were built with data from the study. However, the AUC statistic that was derived from the age-plus-hip-BMD model (0.76) was similar to that obtained with FRAX plus hip BMD (0.75). The AUC statistic for FRAX alone was 0.71. (An AUC of 0.50 reflects a predictive ability equal to chance.)

Similarly, age plus hip BMD had a significantly greater ability to predict both major osteoporotic fractures (hip, clinical spine, wrist, or humerus) and clinical fractures (defined as nonvertebral or clinical vertebral fractures) than did the FRAX algorithm alone, Dr. Ensrud reported at the annual meeting of the American Society for Bone and Mineral Research.

To refine their analysis further, Dr. Ensrud and her associates compared the proportion of women across the models who were classified in the highest decile of fracture risk and who actually experienced a fracture outcome. This type of assessment enhances the clinical usefulness of a risk prediction model because it contains a higher proportion of women who actually experienced the outcome in question, she said.

This simple model of age and prior fracture history (rather than hip BMD) also predicted the 10-year risk of hip, osteoporotic, and clinical fractures just as well as the FRAX algorithm alone did. This finding suggests that “in a setting where BMD is not available, the addition of [complex] clinical risk factor information to age and prior fracture history alone does not enhance the prediction of these fractures in older women,” Dr. Ensrud said.

The study was funded by the National Institute on Aging.

MONTREAL — Loss of bone mineral density over time appears to be more severe in older men with type 2 diabetes than in older men without diabetes, even though men with diabetes have higher average bone mineral density at baseline.

Data from 4 years of follow-up from a prospective study showed that fractures are more likely to occur in older adults with type 2 diabetes than in euglycemic older adults, even though studies have reported that those with type 2 diabetes have 4%–5% higher bone mineral density (BMD) after adjustment for total lean and fat mass. Higher bone loss has been especially noted in older white women with diabetes, especially in those using thiazolidinediones (TZDs), Elsa S. Strotmeyer, Ph.D., said at the annual meeting of the American Society for Bone and Mineral Research.

Dr. Strotmeyer and her associates based their investigation on men in the Osteoporotic Fractures in Men (MrOS) study, which involved osteoporosis screening initially in 2000–2002 and a follow-up exam 4 years later of 5,995 ambulatory, community-dwelling men older than 65 years. The researchers examined dual x-ray absorptiometry exams from 4,094 of these men, who had a mean age of 73 years. Most of them were white (91%), and some had type 2 diabetes (14%) or impaired fasting glucose (IFG, 37%).

Men with diabetes had higher mean BMD at baseline (0.986 g/cm

Despite their greater overall mean BMD, men with diabetes experienced a significantly greater annual decline in BMD at the femoral neck than did the other men. This yearly decrease (−0.562%) occurred at nearly twice the rate seen in men with IFG (−0.313%) or normal fasting glucose (−0.325%).

At the end of follow-up, the bone area of men with diabetes had increased significantly more than in the other men. The men with diabetes also showed a greater loss of bone mineral content, although there was not a statistically significant difference among the groups. This meant that men with diabetes with the lowest bone area at baseline actually had the greatest gain in bone area during the study.

The study received funding from several institutes in the National Institutes of Health.

MONTREAL — Loss of bone mineral density over time appears to be more severe in older men with type 2 diabetes than in older men without diabetes, even though men with diabetes have higher average bone mineral density at baseline.

Data from 4 years of follow-up from a prospective study showed that fractures are more likely to occur in older adults with type 2 diabetes than in euglycemic older adults, even though studies have reported that those with type 2 diabetes have 4%–5% higher bone mineral density (BMD) after adjustment for total lean and fat mass. Higher bone loss has been especially noted in older white women with diabetes, especially in those using thiazolidinediones (TZDs), Elsa S. Strotmeyer, Ph.D., said at the annual meeting of the American Society for Bone and Mineral Research.

Dr. Strotmeyer and her associates based their investigation on men in the Osteoporotic Fractures in Men (MrOS) study, which involved osteoporosis screening initially in 2000–2002 and a follow-up exam 4 years later of 5,995 ambulatory, community-dwelling men older than 65 years. The researchers examined dual x-ray absorptiometry exams from 4,094 of these men, who had a mean age of 73 years. Most of them were white (91%), and some had type 2 diabetes (14%) or impaired fasting glucose (IFG, 37%).

Men with diabetes had higher mean BMD at baseline (0.986 g/cm

Despite their greater overall mean BMD, men with diabetes experienced a significantly greater annual decline in BMD at the femoral neck than did the other men. This yearly decrease (−0.562%) occurred at nearly twice the rate seen in men with IFG (−0.313%) or normal fasting glucose (−0.325%).

At the end of follow-up, the bone area of men with diabetes had increased significantly more than in the other men. The men with diabetes also showed a greater loss of bone mineral content, although there was not a statistically significant difference among the groups. This meant that men with diabetes with the lowest bone area at baseline actually had the greatest gain in bone area during the study.

The study received funding from several institutes in the National Institutes of Health.

MONTREAL — Loss of bone mineral density over time appears to be more severe in older men with type 2 diabetes than in older men without diabetes, even though men with diabetes have higher average bone mineral density at baseline.

Data from 4 years of follow-up from a prospective study showed that fractures are more likely to occur in older adults with type 2 diabetes than in euglycemic older adults, even though studies have reported that those with type 2 diabetes have 4%–5% higher bone mineral density (BMD) after adjustment for total lean and fat mass. Higher bone loss has been especially noted in older white women with diabetes, especially in those using thiazolidinediones (TZDs), Elsa S. Strotmeyer, Ph.D., said at the annual meeting of the American Society for Bone and Mineral Research.

Dr. Strotmeyer and her associates based their investigation on men in the Osteoporotic Fractures in Men (MrOS) study, which involved osteoporosis screening initially in 2000–2002 and a follow-up exam 4 years later of 5,995 ambulatory, community-dwelling men older than 65 years. The researchers examined dual x-ray absorptiometry exams from 4,094 of these men, who had a mean age of 73 years. Most of them were white (91%), and some had type 2 diabetes (14%) or impaired fasting glucose (IFG, 37%).

Men with diabetes had higher mean BMD at baseline (0.986 g/cm

Despite their greater overall mean BMD, men with diabetes experienced a significantly greater annual decline in BMD at the femoral neck than did the other men. This yearly decrease (−0.562%) occurred at nearly twice the rate seen in men with IFG (−0.313%) or normal fasting glucose (−0.325%).

At the end of follow-up, the bone area of men with diabetes had increased significantly more than in the other men. The men with diabetes also showed a greater loss of bone mineral content, although there was not a statistically significant difference among the groups. This meant that men with diabetes with the lowest bone area at baseline actually had the greatest gain in bone area during the study.

The study received funding from several institutes in the National Institutes of Health.

A sufficient amount of the prescription antiviral medication oseltamivir will be available throughout the United States during the upcoming flu season, according to a statement released by its manufacturer, Roche.

Oseltamivir (Tamiflu) can be distributed to pharmacies with low supplies of the drug within 24 hours through a rapid response system that Roche has set up through distributors nationwide.

The drug is indicated for the treatment and prevention of influenza in adults and children aged at least 1 year.

It is the only oral antiviral medication with this indication that is recommended by the Centers for Disease Control and Prevention.

Oseltamivir must be administered within the first 48 hours of flu symptoms in order for it to be effective. It is designed to be active against all clinically relevant influenza virus strains by preventing the virus from spreading inside the body.

A sufficient amount of the prescription antiviral medication oseltamivir will be available throughout the United States during the upcoming flu season, according to a statement released by its manufacturer, Roche.

Oseltamivir (Tamiflu) can be distributed to pharmacies with low supplies of the drug within 24 hours through a rapid response system that Roche has set up through distributors nationwide.

The drug is indicated for the treatment and prevention of influenza in adults and children aged at least 1 year.

It is the only oral antiviral medication with this indication that is recommended by the Centers for Disease Control and Prevention.

Oseltamivir must be administered within the first 48 hours of flu symptoms in order for it to be effective. It is designed to be active against all clinically relevant influenza virus strains by preventing the virus from spreading inside the body.

A sufficient amount of the prescription antiviral medication oseltamivir will be available throughout the United States during the upcoming flu season, according to a statement released by its manufacturer, Roche.

Oseltamivir (Tamiflu) can be distributed to pharmacies with low supplies of the drug within 24 hours through a rapid response system that Roche has set up through distributors nationwide.

The drug is indicated for the treatment and prevention of influenza in adults and children aged at least 1 year.

It is the only oral antiviral medication with this indication that is recommended by the Centers for Disease Control and Prevention.

Oseltamivir must be administered within the first 48 hours of flu symptoms in order for it to be effective. It is designed to be active against all clinically relevant influenza virus strains by preventing the virus from spreading inside the body.

MONTREAL — Consumption of vitamin C at sufficiently high levels is associated with nearly a 50% decrease in the risk of hip and nonvertebral osteoporotic fractures in elderly men and women, according to a 15- to 17-year follow-up of participants in the Framingham Osteoporosis Study.

Previous studies of menopausal and postmenopausal women have shown that dietary intake of vitamin C is associated with increased bone mineral density (BMD), and that a high vitamin C serum level is associated with a decreased prevalence of fracture. Poor dietary intake of vitamin C also has been associated with an increased risk of hip fracture, Marian T. Hannan, D.Sc., said at the annual meeting of the American Society for Bone and Mineral Research.

Vitamin C, an antioxidant, plays an important role in the formation of collagen, which is a major component of connective tissue. Published evidence suggests that oxidative stress may result in increased osteoclast formation, resulting in greater bone resorption, said Dr. Hannan, who presented the study on behalf of Shivani Sahni of Tufts University, Boston. (Ms. Sahni performed the research as a part of her thesis but could not attend the meeting.)

Of 5,209 men and women in the original Framingham Heart Study cohort, the investigators identified 958 individuals who had participated in the beginning of the osteoporosis study in 1988–1989, had answered a food-frequency questionnaire, and had no history of a hip fracture. These individuals had a mean age of 75 years and experienced 100 hip fractures and 180 nonvertebral osteoporotic fractures during the follow-up period, Dr. Hannan reported.

For the study, participants were divided into three groups based on their intake of vitamin C. The relative risk of hip fracture was significantly lower for individuals who had the highest total intake of both dietary and supplemental vitamin C (a median of 305 mg/day) than it was for people with the lowest total intake (median of 97 mg/day). This translated into a 44% decrease in relative risk of hip fracture, according to Dr. Hannan of Harvard Medical School's Institute for Aging Research, Boston.

Those with the highest total intake of vitamin C also had a 36% lower relative risk of having a nonvertebral osteoporotic fracture than did individuals with the lowest total intake.

When the investigators looked at supplemental vitamin C intake alone, the highest users (median of 260 mg/day) had a 70% lower relative risk of hip fracture than did nonusers. Supplements accounted for about 28% of the individuals' total vitamin C intake, she said.

The investigators found no effect for dietary intake of vitamin C alone.

All of the comparisons were adjusted for age, sex, body mass index, height, smoking status, estrogen use in women, physical activity, alcohol use, multivitamin use, femoral neck BMD, and total intake of energy, calcium, vitamin D, and potassium.

One audience member suggested that the discrepancy between the effects of supplemental and dietary vitamin C intake could mean that there are residual confounding effects from factors that were not accounted for in the study, such that supplemental use of vitamin C may be a marker for people who care more about their health and take better care of themselves. This is a problem that can only be answered with a randomized, controlled trial, Dr. Hannan noted.

“We were intrigued by the lack of a BMD effect on [the association between] vitamin C and fracture, and we believe that it implies that vitamin C may affect a different pathway or other fracture risk factors, for example, fall risk factors or mobility risk factors,” Dr. Hannan said.

MONTREAL — Consumption of vitamin C at sufficiently high levels is associated with nearly a 50% decrease in the risk of hip and nonvertebral osteoporotic fractures in elderly men and women, according to a 15- to 17-year follow-up of participants in the Framingham Osteoporosis Study.

Previous studies of menopausal and postmenopausal women have shown that dietary intake of vitamin C is associated with increased bone mineral density (BMD), and that a high vitamin C serum level is associated with a decreased prevalence of fracture. Poor dietary intake of vitamin C also has been associated with an increased risk of hip fracture, Marian T. Hannan, D.Sc., said at the annual meeting of the American Society for Bone and Mineral Research.

Vitamin C, an antioxidant, plays an important role in the formation of collagen, which is a major component of connective tissue. Published evidence suggests that oxidative stress may result in increased osteoclast formation, resulting in greater bone resorption, said Dr. Hannan, who presented the study on behalf of Shivani Sahni of Tufts University, Boston. (Ms. Sahni performed the research as a part of her thesis but could not attend the meeting.)

Of 5,209 men and women in the original Framingham Heart Study cohort, the investigators identified 958 individuals who had participated in the beginning of the osteoporosis study in 1988–1989, had answered a food-frequency questionnaire, and had no history of a hip fracture. These individuals had a mean age of 75 years and experienced 100 hip fractures and 180 nonvertebral osteoporotic fractures during the follow-up period, Dr. Hannan reported.

For the study, participants were divided into three groups based on their intake of vitamin C. The relative risk of hip fracture was significantly lower for individuals who had the highest total intake of both dietary and supplemental vitamin C (a median of 305 mg/day) than it was for people with the lowest total intake (median of 97 mg/day). This translated into a 44% decrease in relative risk of hip fracture, according to Dr. Hannan of Harvard Medical School's Institute for Aging Research, Boston.

Those with the highest total intake of vitamin C also had a 36% lower relative risk of having a nonvertebral osteoporotic fracture than did individuals with the lowest total intake.

When the investigators looked at supplemental vitamin C intake alone, the highest users (median of 260 mg/day) had a 70% lower relative risk of hip fracture than did nonusers. Supplements accounted for about 28% of the individuals' total vitamin C intake, she said.

The investigators found no effect for dietary intake of vitamin C alone.

All of the comparisons were adjusted for age, sex, body mass index, height, smoking status, estrogen use in women, physical activity, alcohol use, multivitamin use, femoral neck BMD, and total intake of energy, calcium, vitamin D, and potassium.

One audience member suggested that the discrepancy between the effects of supplemental and dietary vitamin C intake could mean that there are residual confounding effects from factors that were not accounted for in the study, such that supplemental use of vitamin C may be a marker for people who care more about their health and take better care of themselves. This is a problem that can only be answered with a randomized, controlled trial, Dr. Hannan noted.

“We were intrigued by the lack of a BMD effect on [the association between] vitamin C and fracture, and we believe that it implies that vitamin C may affect a different pathway or other fracture risk factors, for example, fall risk factors or mobility risk factors,” Dr. Hannan said.

MONTREAL — Consumption of vitamin C at sufficiently high levels is associated with nearly a 50% decrease in the risk of hip and nonvertebral osteoporotic fractures in elderly men and women, according to a 15- to 17-year follow-up of participants in the Framingham Osteoporosis Study.

Previous studies of menopausal and postmenopausal women have shown that dietary intake of vitamin C is associated with increased bone mineral density (BMD), and that a high vitamin C serum level is associated with a decreased prevalence of fracture. Poor dietary intake of vitamin C also has been associated with an increased risk of hip fracture, Marian T. Hannan, D.Sc., said at the annual meeting of the American Society for Bone and Mineral Research.

Vitamin C, an antioxidant, plays an important role in the formation of collagen, which is a major component of connective tissue. Published evidence suggests that oxidative stress may result in increased osteoclast formation, resulting in greater bone resorption, said Dr. Hannan, who presented the study on behalf of Shivani Sahni of Tufts University, Boston. (Ms. Sahni performed the research as a part of her thesis but could not attend the meeting.)

Of 5,209 men and women in the original Framingham Heart Study cohort, the investigators identified 958 individuals who had participated in the beginning of the osteoporosis study in 1988–1989, had answered a food-frequency questionnaire, and had no history of a hip fracture. These individuals had a mean age of 75 years and experienced 100 hip fractures and 180 nonvertebral osteoporotic fractures during the follow-up period, Dr. Hannan reported.

For the study, participants were divided into three groups based on their intake of vitamin C. The relative risk of hip fracture was significantly lower for individuals who had the highest total intake of both dietary and supplemental vitamin C (a median of 305 mg/day) than it was for people with the lowest total intake (median of 97 mg/day). This translated into a 44% decrease in relative risk of hip fracture, according to Dr. Hannan of Harvard Medical School's Institute for Aging Research, Boston.

Those with the highest total intake of vitamin C also had a 36% lower relative risk of having a nonvertebral osteoporotic fracture than did individuals with the lowest total intake.

When the investigators looked at supplemental vitamin C intake alone, the highest users (median of 260 mg/day) had a 70% lower relative risk of hip fracture than did nonusers. Supplements accounted for about 28% of the individuals' total vitamin C intake, she said.

The investigators found no effect for dietary intake of vitamin C alone.

All of the comparisons were adjusted for age, sex, body mass index, height, smoking status, estrogen use in women, physical activity, alcohol use, multivitamin use, femoral neck BMD, and total intake of energy, calcium, vitamin D, and potassium.

One audience member suggested that the discrepancy between the effects of supplemental and dietary vitamin C intake could mean that there are residual confounding effects from factors that were not accounted for in the study, such that supplemental use of vitamin C may be a marker for people who care more about their health and take better care of themselves. This is a problem that can only be answered with a randomized, controlled trial, Dr. Hannan noted.

“We were intrigued by the lack of a BMD effect on [the association between] vitamin C and fracture, and we believe that it implies that vitamin C may affect a different pathway or other fracture risk factors, for example, fall risk factors or mobility risk factors,” Dr. Hannan said.

MONTREAL — A history of unresponsiveness to bisphosphonate therapies does not appear to diminish the bone-building effects of teriparatide in women with osteoporosis, judging from the findings of a small, uncontrolled, 18-month study.

The anabolic effects of teriparatide (Forteo), an injectable form of recombinant human parathyroid hormone, on bone mineral density (BMD) were apparent by 6 months into treatment and were accompanied by significant changes in biomarkers of bone turnover and positive changes in bone structure on MicroCT imaging, Dr. Burkhard Muche said at the annual meeting of the American Society for Bone and Mineral Research.

The results suggest that patients who are resistant to oral bisphosphonate therapy could use teriparatide in treatment cycles lasting at least 6 months, followed by an antiresorptive agent such as raloxifene (Evista), strontium ranelate, or an intravenous bisphosphonate, in order to optimize the beneficial effects of the anabolic agent, said Dr. Muche of the department of metabolic diseases/osteology at Immanuel-Krankenhaus, Berlin.

Of 25 women in the study with a mean age of 69 years, 14 had a new fragility fracture and 11 had a significant decline in BMD of greater than 3.5%, despite previous treatment with oral bisphosphonates lasting at least 12 months. Half had taken risedronate (Actonel) and half had taken alendronate (Fosamax) for a mean of 3.5 years (range of 1–7 years). The women also received 500 mg of calcium and 400 IU of vitamin D3 each day.

The investigators detected significant increases in BMD at the lumbar spine after 6, 12, and 18 months of teriparatide. By 18 months, the women had a mean 9% increase in BMD at the lumbar spine. No significant changes developed in the total BMD of the femoral neck or the hip.

Intermittent asymptomatic hypercalcemia occurred in four patients.

Levels of the bone formation marker bone alkaline phosphatase significantly increased from 15 ng/L at baseline to 28 ng/L at 6 months, but then decreased through 18 months. Concentrations of a marker of bone resorption, beta C-terminal telopeptide of type I collagen (α-CTX), followed the same trend.

Dr. Muche and his colleagues obtained paired bone biopsies from the dorsal iliac crest at baseline, from the opposite side at 6 months, and again from the original side at 18 months. Parameters of bone structure on MicroCT imaging increased early during the course of treatment.

Dr. Muche received a travel grant from Lilly Germany, which funded the study. Eli Lilly & Co. makes teriparatide.

MONTREAL — A history of unresponsiveness to bisphosphonate therapies does not appear to diminish the bone-building effects of teriparatide in women with osteoporosis, judging from the findings of a small, uncontrolled, 18-month study.

The anabolic effects of teriparatide (Forteo), an injectable form of recombinant human parathyroid hormone, on bone mineral density (BMD) were apparent by 6 months into treatment and were accompanied by significant changes in biomarkers of bone turnover and positive changes in bone structure on MicroCT imaging, Dr. Burkhard Muche said at the annual meeting of the American Society for Bone and Mineral Research.

The results suggest that patients who are resistant to oral bisphosphonate therapy could use teriparatide in treatment cycles lasting at least 6 months, followed by an antiresorptive agent such as raloxifene (Evista), strontium ranelate, or an intravenous bisphosphonate, in order to optimize the beneficial effects of the anabolic agent, said Dr. Muche of the department of metabolic diseases/osteology at Immanuel-Krankenhaus, Berlin.

Of 25 women in the study with a mean age of 69 years, 14 had a new fragility fracture and 11 had a significant decline in BMD of greater than 3.5%, despite previous treatment with oral bisphosphonates lasting at least 12 months. Half had taken risedronate (Actonel) and half had taken alendronate (Fosamax) for a mean of 3.5 years (range of 1–7 years). The women also received 500 mg of calcium and 400 IU of vitamin D3 each day.

The investigators detected significant increases in BMD at the lumbar spine after 6, 12, and 18 months of teriparatide. By 18 months, the women had a mean 9% increase in BMD at the lumbar spine. No significant changes developed in the total BMD of the femoral neck or the hip.

Intermittent asymptomatic hypercalcemia occurred in four patients.

Levels of the bone formation marker bone alkaline phosphatase significantly increased from 15 ng/L at baseline to 28 ng/L at 6 months, but then decreased through 18 months. Concentrations of a marker of bone resorption, beta C-terminal telopeptide of type I collagen (α-CTX), followed the same trend.

Dr. Muche and his colleagues obtained paired bone biopsies from the dorsal iliac crest at baseline, from the opposite side at 6 months, and again from the original side at 18 months. Parameters of bone structure on MicroCT imaging increased early during the course of treatment.

Dr. Muche received a travel grant from Lilly Germany, which funded the study. Eli Lilly & Co. makes teriparatide.

MONTREAL — A history of unresponsiveness to bisphosphonate therapies does not appear to diminish the bone-building effects of teriparatide in women with osteoporosis, judging from the findings of a small, uncontrolled, 18-month study.

The anabolic effects of teriparatide (Forteo), an injectable form of recombinant human parathyroid hormone, on bone mineral density (BMD) were apparent by 6 months into treatment and were accompanied by significant changes in biomarkers of bone turnover and positive changes in bone structure on MicroCT imaging, Dr. Burkhard Muche said at the annual meeting of the American Society for Bone and Mineral Research.

The results suggest that patients who are resistant to oral bisphosphonate therapy could use teriparatide in treatment cycles lasting at least 6 months, followed by an antiresorptive agent such as raloxifene (Evista), strontium ranelate, or an intravenous bisphosphonate, in order to optimize the beneficial effects of the anabolic agent, said Dr. Muche of the department of metabolic diseases/osteology at Immanuel-Krankenhaus, Berlin.

Of 25 women in the study with a mean age of 69 years, 14 had a new fragility fracture and 11 had a significant decline in BMD of greater than 3.5%, despite previous treatment with oral bisphosphonates lasting at least 12 months. Half had taken risedronate (Actonel) and half had taken alendronate (Fosamax) for a mean of 3.5 years (range of 1–7 years). The women also received 500 mg of calcium and 400 IU of vitamin D3 each day.

The investigators detected significant increases in BMD at the lumbar spine after 6, 12, and 18 months of teriparatide. By 18 months, the women had a mean 9% increase in BMD at the lumbar spine. No significant changes developed in the total BMD of the femoral neck or the hip.

Intermittent asymptomatic hypercalcemia occurred in four patients.

Levels of the bone formation marker bone alkaline phosphatase significantly increased from 15 ng/L at baseline to 28 ng/L at 6 months, but then decreased through 18 months. Concentrations of a marker of bone resorption, beta C-terminal telopeptide of type I collagen (α-CTX), followed the same trend.

Dr. Muche and his colleagues obtained paired bone biopsies from the dorsal iliac crest at baseline, from the opposite side at 6 months, and again from the original side at 18 months. Parameters of bone structure on MicroCT imaging increased early during the course of treatment.

Dr. Muche received a travel grant from Lilly Germany, which funded the study. Eli Lilly & Co. makes teriparatide.

MONTREAL — Consumption of vitamin C at sufficiently high levels is associated with nearly a 50% decrease in the risk of hip and nonvertebral osteoporotic fractures in elderly men and women, according to a 15- to 17-year follow-up of patients in the Framingham Osteoporosis Study.

Previous studies of menopausal and postmenopausal women have shown that dietary intake of vitamin C is associated with increased bone mineral density (BMD), and that a high vitamin C serum level is associated with a decreased prevalence of fracture. Poor dietary intake of vitamin C also has been associated with an increased risk of hip fracture, Marian T. Hannan, D.Sc., said at the annual meeting of the American Society for Bone and Mineral Research.

Vitamin C, an antioxidant, plays an important role in the formation of collagen, which is a major component of connective tissue. Published evidence suggests that oxidative stress may result in increased osteoclast formation, resulting in greater bone resorption, said Dr. Hannan, who presented the study on behalf of Shivani Sahni of Tufts University, Boston. (Ms. Sahni performed the research as a part of her thesis but could not attend the meeting.)

Of 5,209 men and women in the original Framingham Heart Study cohort, the investigators identified 958 individuals who had participated in the beginning of the osteoporosis study in 1988–1989, had answered a food-frequency questionnaire, and had no history of a hip fracture. These individuals had a mean age of 75 years and experienced 100 hip fractures and 180 nonvertebral osteoporotic fractures during the follow-up period, Dr. Hannan reported.

For the study, participants were divided into three groups based on their intake of vitamin C. The relative risk of hip fracture was significantly lower for individuals who had the highest total intake of both dietary and supplemental vitamin C (a median of 305 mg/day) than it was for people with the lowest total intake (median of 97 mg/day). This translated into a 44% decrease in relative risk of hip fracture, according to Dr. Hannan of Harvard Medical School's Institute for Aging Research, Boston.

Those with the highest total intake of vitamin C also had a 36% lower relative risk of having a nonvertebral osteoporotic fracture than did individuals with the lowest total intake.

When the investigators looked at supplemental vitamin C intake alone, the highest users (median of 260 mg/day) had a 70% lower relative risk of hip fracture than did nonusers. Supplements accounted for about 28% of the individuals' total vitamin C intake, Dr. Hannan said.

The investigators found no effect for dietary intake of vitamin C alone.

All of the comparisons were adjusted for age, sex, body mass index, height, smoking status, estrogen use in women, physical activity, alcohol use, multivitamin use, femoral neck BMD, and total intake of energy, calcium, vitamin D, and potassium.

One audience member suggested that the discrepancy between the effects of supplemental and dietary vitamin C intake could mean that there are residual confounding effects from factors that were not accounted for in the study, such that supplemental use of vitamin C may be a marker for people who care more about their health and take better care of themselves. This is a problem that can only be answered with a randomized, controlled trial, Dr. Hannan noted.

“We were intrigued by the lack of a BMD effect on [the association between] vitamin C and fracture, and we believe that it implies that vitamin C may affect a different pathway or other fracture risk factors, for example, fall risk factors or mobility risk factors,” Dr. Hannan said.

Future research should investigate “alternative mechanisms for vitamin C that are independent of BMD … [and] evaluate whether an increase in the recommended dietary intake for vitamin C should take into account the preventive effects seen in this study” and in other types of studies, as well as the protective effects that vitamin C has in other chronic diseases.

MONTREAL — Consumption of vitamin C at sufficiently high levels is associated with nearly a 50% decrease in the risk of hip and nonvertebral osteoporotic fractures in elderly men and women, according to a 15- to 17-year follow-up of patients in the Framingham Osteoporosis Study.

Previous studies of menopausal and postmenopausal women have shown that dietary intake of vitamin C is associated with increased bone mineral density (BMD), and that a high vitamin C serum level is associated with a decreased prevalence of fracture. Poor dietary intake of vitamin C also has been associated with an increased risk of hip fracture, Marian T. Hannan, D.Sc., said at the annual meeting of the American Society for Bone and Mineral Research.

Vitamin C, an antioxidant, plays an important role in the formation of collagen, which is a major component of connective tissue. Published evidence suggests that oxidative stress may result in increased osteoclast formation, resulting in greater bone resorption, said Dr. Hannan, who presented the study on behalf of Shivani Sahni of Tufts University, Boston. (Ms. Sahni performed the research as a part of her thesis but could not attend the meeting.)

Of 5,209 men and women in the original Framingham Heart Study cohort, the investigators identified 958 individuals who had participated in the beginning of the osteoporosis study in 1988–1989, had answered a food-frequency questionnaire, and had no history of a hip fracture. These individuals had a mean age of 75 years and experienced 100 hip fractures and 180 nonvertebral osteoporotic fractures during the follow-up period, Dr. Hannan reported.

For the study, participants were divided into three groups based on their intake of vitamin C. The relative risk of hip fracture was significantly lower for individuals who had the highest total intake of both dietary and supplemental vitamin C (a median of 305 mg/day) than it was for people with the lowest total intake (median of 97 mg/day). This translated into a 44% decrease in relative risk of hip fracture, according to Dr. Hannan of Harvard Medical School's Institute for Aging Research, Boston.

Those with the highest total intake of vitamin C also had a 36% lower relative risk of having a nonvertebral osteoporotic fracture than did individuals with the lowest total intake.

When the investigators looked at supplemental vitamin C intake alone, the highest users (median of 260 mg/day) had a 70% lower relative risk of hip fracture than did nonusers. Supplements accounted for about 28% of the individuals' total vitamin C intake, Dr. Hannan said.

The investigators found no effect for dietary intake of vitamin C alone.

All of the comparisons were adjusted for age, sex, body mass index, height, smoking status, estrogen use in women, physical activity, alcohol use, multivitamin use, femoral neck BMD, and total intake of energy, calcium, vitamin D, and potassium.

One audience member suggested that the discrepancy between the effects of supplemental and dietary vitamin C intake could mean that there are residual confounding effects from factors that were not accounted for in the study, such that supplemental use of vitamin C may be a marker for people who care more about their health and take better care of themselves. This is a problem that can only be answered with a randomized, controlled trial, Dr. Hannan noted.

“We were intrigued by the lack of a BMD effect on [the association between] vitamin C and fracture, and we believe that it implies that vitamin C may affect a different pathway or other fracture risk factors, for example, fall risk factors or mobility risk factors,” Dr. Hannan said.

Future research should investigate “alternative mechanisms for vitamin C that are independent of BMD … [and] evaluate whether an increase in the recommended dietary intake for vitamin C should take into account the preventive effects seen in this study” and in other types of studies, as well as the protective effects that vitamin C has in other chronic diseases.

MONTREAL — Consumption of vitamin C at sufficiently high levels is associated with nearly a 50% decrease in the risk of hip and nonvertebral osteoporotic fractures in elderly men and women, according to a 15- to 17-year follow-up of patients in the Framingham Osteoporosis Study.

Previous studies of menopausal and postmenopausal women have shown that dietary intake of vitamin C is associated with increased bone mineral density (BMD), and that a high vitamin C serum level is associated with a decreased prevalence of fracture. Poor dietary intake of vitamin C also has been associated with an increased risk of hip fracture, Marian T. Hannan, D.Sc., said at the annual meeting of the American Society for Bone and Mineral Research.

Vitamin C, an antioxidant, plays an important role in the formation of collagen, which is a major component of connective tissue. Published evidence suggests that oxidative stress may result in increased osteoclast formation, resulting in greater bone resorption, said Dr. Hannan, who presented the study on behalf of Shivani Sahni of Tufts University, Boston. (Ms. Sahni performed the research as a part of her thesis but could not attend the meeting.)

Of 5,209 men and women in the original Framingham Heart Study cohort, the investigators identified 958 individuals who had participated in the beginning of the osteoporosis study in 1988–1989, had answered a food-frequency questionnaire, and had no history of a hip fracture. These individuals had a mean age of 75 years and experienced 100 hip fractures and 180 nonvertebral osteoporotic fractures during the follow-up period, Dr. Hannan reported.

For the study, participants were divided into three groups based on their intake of vitamin C. The relative risk of hip fracture was significantly lower for individuals who had the highest total intake of both dietary and supplemental vitamin C (a median of 305 mg/day) than it was for people with the lowest total intake (median of 97 mg/day). This translated into a 44% decrease in relative risk of hip fracture, according to Dr. Hannan of Harvard Medical School's Institute for Aging Research, Boston.

Those with the highest total intake of vitamin C also had a 36% lower relative risk of having a nonvertebral osteoporotic fracture than did individuals with the lowest total intake.

When the investigators looked at supplemental vitamin C intake alone, the highest users (median of 260 mg/day) had a 70% lower relative risk of hip fracture than did nonusers. Supplements accounted for about 28% of the individuals' total vitamin C intake, Dr. Hannan said.

The investigators found no effect for dietary intake of vitamin C alone.

All of the comparisons were adjusted for age, sex, body mass index, height, smoking status, estrogen use in women, physical activity, alcohol use, multivitamin use, femoral neck BMD, and total intake of energy, calcium, vitamin D, and potassium.

One audience member suggested that the discrepancy between the effects of supplemental and dietary vitamin C intake could mean that there are residual confounding effects from factors that were not accounted for in the study, such that supplemental use of vitamin C may be a marker for people who care more about their health and take better care of themselves. This is a problem that can only be answered with a randomized, controlled trial, Dr. Hannan noted.

“We were intrigued by the lack of a BMD effect on [the association between] vitamin C and fracture, and we believe that it implies that vitamin C may affect a different pathway or other fracture risk factors, for example, fall risk factors or mobility risk factors,” Dr. Hannan said.

Future research should investigate “alternative mechanisms for vitamin C that are independent of BMD … [and] evaluate whether an increase in the recommended dietary intake for vitamin C should take into account the preventive effects seen in this study” and in other types of studies, as well as the protective effects that vitamin C has in other chronic diseases.

WASHINGTON — The rate of illicit drug use in adolescents and young adults stayed relatively steady in 2007, showing mild decreases in use for many drugs.

But drug use continues to be carried into older age by baby boomers, especially those aged 55–59 years, which more than doubled its rate of illicit drug use during 2002–2007, according to the results of the 2007 National Survey on Drug Use and Health.

The increase might partly reflect the aging of baby boomers, who have had higher lifetime rates of illicit drug use than did those in older age groups, according to Eric B. Broderick, D.D.S., acting administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA).

“While the survey results demonstrate that as a nation we are moving in the right direction, they also show how much work remains to be done to confront drug use and drug users in an honest and direct way,” Dr. Broderick said at a press briefing sponsored by SAMHSA.

Compared with the 2002 survey data, in the current survey, youth aged 12–17 years reported declining use of nearly every type of illicit drug, as well as alcohol, cigarette smoking, and nonmedical use of prescription drugs, particularly pain relievers. Young adults aged 18–25 years had significant declines in hallucinogens and methamphetamine use, but their nonmedical use of prescription drugs rose (see graphic).

The survey measured a sample of nearly 68,000 in the general U.S. civilian population, aged 12 years or older. The methodology was improved in 2002, when the survey name was changed from the National Household Survey on Drug Abuse.

For 2006–2007, individuals aged 18–25 years reported significant decreases in the use of cocaine by 23% (from 2.2% to 1.7%) and the use of methamphetamine by 33% (from 0.6% to 0.4%). This trend may be attributable to lower rates of use by teenagers who have now aged into young adulthood, as well as substantial disruption of the markets for both drugs over the past 18 months, said John P. Walters, director of the Office of National Drug Control Policy.

Mr. Walters thought that if the current generation of adolescents and young adults have less exposure to drugs, then fewer of them will use drugs later in life. The current spike in illicit drug use by individuals aged 55–59 years, from 1.9% in 2002 to 4.1% in 2007, shows that past drug use from the baby boomer population has carried on later into life, compared with the significantly lower rates of use seen in previous generations in that age group.

An estimated 23.2 million people needed treatment for substance abuse or dependence in 2007, but only 2.4 million people received treatment at a specialty facility. Of the remaining 20.8 million who did not receive care, nearly 94% felt that they did not need treatment. The large number of people who do not feel they need treatment “is something we absolutely need to change,” Dr. Broderick said.

He said that while intervention initiatives have been successful in some programs, opportunities for care will continue to be lost “unless we focus on the full continuum of care and treat substance abuse with the same urgency that we treat other health conditions.” Dr. Broderick suggested that one way to make this happen could be in strengthening the integration of substance use and behavioral health services into the primary care system.

Dr. Broderick cited SAMHSA's Screening, Brief Intervention, and Referral to Treatment (SBIRT) program as a successful example of intervening early and integrating care across disciplines.

The current spike in illicit drug use in baby boomers shows past drug use has carried on into later life. MR. WALTERS

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — The rate of illicit drug use in adolescents and young adults stayed relatively steady in 2007, showing mild decreases in use for many drugs.

But drug use continues to be carried into older age by baby boomers, especially those aged 55–59 years, which more than doubled its rate of illicit drug use during 2002–2007, according to the results of the 2007 National Survey on Drug Use and Health.

The increase might partly reflect the aging of baby boomers, who have had higher lifetime rates of illicit drug use than did those in older age groups, according to Eric B. Broderick, D.D.S., acting administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA).

“While the survey results demonstrate that as a nation we are moving in the right direction, they also show how much work remains to be done to confront drug use and drug users in an honest and direct way,” Dr. Broderick said at a press briefing sponsored by SAMHSA.

Compared with the 2002 survey data, in the current survey, youth aged 12–17 years reported declining use of nearly every type of illicit drug, as well as alcohol, cigarette smoking, and nonmedical use of prescription drugs, particularly pain relievers. Young adults aged 18–25 years had significant declines in hallucinogens and methamphetamine use, but their nonmedical use of prescription drugs rose (see graphic).

The survey measured a sample of nearly 68,000 in the general U.S. civilian population, aged 12 years or older. The methodology was improved in 2002, when the survey name was changed from the National Household Survey on Drug Abuse.

For 2006–2007, individuals aged 18–25 years reported significant decreases in the use of cocaine by 23% (from 2.2% to 1.7%) and the use of methamphetamine by 33% (from 0.6% to 0.4%). This trend may be attributable to lower rates of use by teenagers who have now aged into young adulthood, as well as substantial disruption of the markets for both drugs over the past 18 months, said John P. Walters, director of the Office of National Drug Control Policy.

Mr. Walters thought that if the current generation of adolescents and young adults have less exposure to drugs, then fewer of them will use drugs later in life. The current spike in illicit drug use by individuals aged 55–59 years, from 1.9% in 2002 to 4.1% in 2007, shows that past drug use from the baby boomer population has carried on later into life, compared with the significantly lower rates of use seen in previous generations in that age group.

An estimated 23.2 million people needed treatment for substance abuse or dependence in 2007, but only 2.4 million people received treatment at a specialty facility. Of the remaining 20.8 million who did not receive care, nearly 94% felt that they did not need treatment. The large number of people who do not feel they need treatment “is something we absolutely need to change,” Dr. Broderick said.

He said that while intervention initiatives have been successful in some programs, opportunities for care will continue to be lost “unless we focus on the full continuum of care and treat substance abuse with the same urgency that we treat other health conditions.” Dr. Broderick suggested that one way to make this happen could be in strengthening the integration of substance use and behavioral health services into the primary care system.

Dr. Broderick cited SAMHSA's Screening, Brief Intervention, and Referral to Treatment (SBIRT) program as a successful example of intervening early and integrating care across disciplines.

The current spike in illicit drug use in baby boomers shows past drug use has carried on into later life. MR. WALTERS

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — The rate of illicit drug use in adolescents and young adults stayed relatively steady in 2007, showing mild decreases in use for many drugs.

But drug use continues to be carried into older age by baby boomers, especially those aged 55–59 years, which more than doubled its rate of illicit drug use during 2002–2007, according to the results of the 2007 National Survey on Drug Use and Health.

The increase might partly reflect the aging of baby boomers, who have had higher lifetime rates of illicit drug use than did those in older age groups, according to Eric B. Broderick, D.D.S., acting administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA).

“While the survey results demonstrate that as a nation we are moving in the right direction, they also show how much work remains to be done to confront drug use and drug users in an honest and direct way,” Dr. Broderick said at a press briefing sponsored by SAMHSA.

Compared with the 2002 survey data, in the current survey, youth aged 12–17 years reported declining use of nearly every type of illicit drug, as well as alcohol, cigarette smoking, and nonmedical use of prescription drugs, particularly pain relievers. Young adults aged 18–25 years had significant declines in hallucinogens and methamphetamine use, but their nonmedical use of prescription drugs rose (see graphic).

The survey measured a sample of nearly 68,000 in the general U.S. civilian population, aged 12 years or older. The methodology was improved in 2002, when the survey name was changed from the National Household Survey on Drug Abuse.

For 2006–2007, individuals aged 18–25 years reported significant decreases in the use of cocaine by 23% (from 2.2% to 1.7%) and the use of methamphetamine by 33% (from 0.6% to 0.4%). This trend may be attributable to lower rates of use by teenagers who have now aged into young adulthood, as well as substantial disruption of the markets for both drugs over the past 18 months, said John P. Walters, director of the Office of National Drug Control Policy.

Mr. Walters thought that if the current generation of adolescents and young adults have less exposure to drugs, then fewer of them will use drugs later in life. The current spike in illicit drug use by individuals aged 55–59 years, from 1.9% in 2002 to 4.1% in 2007, shows that past drug use from the baby boomer population has carried on later into life, compared with the significantly lower rates of use seen in previous generations in that age group.

An estimated 23.2 million people needed treatment for substance abuse or dependence in 2007, but only 2.4 million people received treatment at a specialty facility. Of the remaining 20.8 million who did not receive care, nearly 94% felt that they did not need treatment. The large number of people who do not feel they need treatment “is something we absolutely need to change,” Dr. Broderick said.

He said that while intervention initiatives have been successful in some programs, opportunities for care will continue to be lost “unless we focus on the full continuum of care and treat substance abuse with the same urgency that we treat other health conditions.” Dr. Broderick suggested that one way to make this happen could be in strengthening the integration of substance use and behavioral health services into the primary care system.

Dr. Broderick cited SAMHSA's Screening, Brief Intervention, and Referral to Treatment (SBIRT) program as a successful example of intervening early and integrating care across disciplines.

The current spike in illicit drug use in baby boomers shows past drug use has carried on into later life. MR. WALTERS

ELSEVIER GLOBAL MEDICAL NEWS

Gout patients have equal rates of success in attaining a serum urate concentration of 0.30 mmol/L or less—a value thought to predict good control of flares and a reduction of tophi—with either allopurinol or benzbromarone, as long as the doses are slightly higher than normal and based on serum urate values, according to the results of a randomized, open-label trial.

The data were presented at the annual meeting of the European League Against Rheumatism in Paris.

“In this small study, tolerability is not affected by doubling the dosage in patients not reaching target levels,” study investigator Mattheus Reinders, a hospital pharmacist at the Atrium Medisch Centrum, Heerlen (the Netherlands), said in an interview.

The results of the study make it clear that there is no difference in efficacy between allopurinol and benzbromarone when given in adequate doses, despite their different mechanisms of action. It also shows “allopurinol must be dosed higher than usually done in trials and in clinical practice [300 mg/day] to reach target serum levels,” Mr. Reinders said.

Gout flares and tophi mostly occur in those body parts with the lowest temperature: the extremities. It is often said that serum urate (uric acid) concentration—a well-accepted biomarker for evaluation of gout treatment—must be lower than the solubility at 37 °C (0.42 mmol/L) for good treatment.

But solubility drops dramatically with lower temperature, and so lower serum urate values are needed.

A serum urate concentration of 0.30 mmol/L or lower has been shown to be adequate in previous research, Mr. Reinders said in the interview.

EULAR's evidence-based recommendations for gout advise titrating the allopurinol dosage according to the level of serum urate that is attained. There is a lack of information about this approach and the effects of the higher dosages of serum urate-lowering drugs that will be required to decrease serum urate in patients who are not reaching target levels. Many clinicians also are prescribing only a fixed dosage of allopurinol 300 mg/day, he said.

Therefore, Mr. Reinders and his coinvestigators randomized 55 patients with newly diagnosed gout in an open-label trial comparing the efficacy and tolerability of allopurinol and benzbromarone. Allopurinol began at a dosage of 300 mg/day and was increased to 600 mg/day if necessary, while benzbromarone started at 100 mg/day and could be increased to 200 mg/day.

The gout diagnosis was confirmed by microscopic evidence of urate crystals in punctate from synovial fluid or periarticular structures or presence of tophi. The patients were indicated for serum urate-lowering treatment if they had tophi or more than two gout attacks per year. None of the patients had relevant liver or renal disease, and none had previously received either medication. Mr. Reinders conducted the research when he was in training at the Medisch Centrum Leeuwarden, also in the Netherlands, which funded the study.

After 2 months of treatment, a significantly greater percentage of patients who took benzbromarone 100 mg/day reached the target serum urate concentration of 0.30 mmol/L (13 of 25 patients, or 52%) than did patients who took allopurinol 300 mg/day (8 of 30 patients, or 27%).

After the investigators doubled the daily dosage of each drug in patients who had not met the treatment target, there was no significant difference in the total percentage of patients who had successful treatment with allopurinol (21 of 27, or 78%), compared with benzbromarone (18 of 23, or 78%).

Even before the dose increase, two patients stopped taking allopurinol and three stopped taking benzbromarone because of adverse drug reactions.

No more adverse reactions occurred after the dosages were increased in the nonresponders.

'Allopurinol must be dosed higher than usually done in trials and in clinical practice to reach target serum levels.' MR. REINDERS

Gout patients have equal rates of success in attaining a serum urate concentration of 0.30 mmol/L or less—a value thought to predict good control of flares and a reduction of tophi—with either allopurinol or benzbromarone, as long as the doses are slightly higher than normal and based on serum urate values, according to the results of a randomized, open-label trial.

The data were presented at the annual meeting of the European League Against Rheumatism in Paris.

“In this small study, tolerability is not affected by doubling the dosage in patients not reaching target levels,” study investigator Mattheus Reinders, a hospital pharmacist at the Atrium Medisch Centrum, Heerlen (the Netherlands), said in an interview.

The results of the study make it clear that there is no difference in efficacy between allopurinol and benzbromarone when given in adequate doses, despite their different mechanisms of action. It also shows “allopurinol must be dosed higher than usually done in trials and in clinical practice [300 mg/day] to reach target serum levels,” Mr. Reinders said.

Gout flares and tophi mostly occur in those body parts with the lowest temperature: the extremities. It is often said that serum urate (uric acid) concentration—a well-accepted biomarker for evaluation of gout treatment—must be lower than the solubility at 37 °C (0.42 mmol/L) for good treatment.

But solubility drops dramatically with lower temperature, and so lower serum urate values are needed.

A serum urate concentration of 0.30 mmol/L or lower has been shown to be adequate in previous research, Mr. Reinders said in the interview.

EULAR's evidence-based recommendations for gout advise titrating the allopurinol dosage according to the level of serum urate that is attained. There is a lack of information about this approach and the effects of the higher dosages of serum urate-lowering drugs that will be required to decrease serum urate in patients who are not reaching target levels. Many clinicians also are prescribing only a fixed dosage of allopurinol 300 mg/day, he said.

Therefore, Mr. Reinders and his coinvestigators randomized 55 patients with newly diagnosed gout in an open-label trial comparing the efficacy and tolerability of allopurinol and benzbromarone. Allopurinol began at a dosage of 300 mg/day and was increased to 600 mg/day if necessary, while benzbromarone started at 100 mg/day and could be increased to 200 mg/day.

The gout diagnosis was confirmed by microscopic evidence of urate crystals in punctate from synovial fluid or periarticular structures or presence of tophi. The patients were indicated for serum urate-lowering treatment if they had tophi or more than two gout attacks per year. None of the patients had relevant liver or renal disease, and none had previously received either medication. Mr. Reinders conducted the research when he was in training at the Medisch Centrum Leeuwarden, also in the Netherlands, which funded the study.

After 2 months of treatment, a significantly greater percentage of patients who took benzbromarone 100 mg/day reached the target serum urate concentration of 0.30 mmol/L (13 of 25 patients, or 52%) than did patients who took allopurinol 300 mg/day (8 of 30 patients, or 27%).

After the investigators doubled the daily dosage of each drug in patients who had not met the treatment target, there was no significant difference in the total percentage of patients who had successful treatment with allopurinol (21 of 27, or 78%), compared with benzbromarone (18 of 23, or 78%).

Even before the dose increase, two patients stopped taking allopurinol and three stopped taking benzbromarone because of adverse drug reactions.

No more adverse reactions occurred after the dosages were increased in the nonresponders.

'Allopurinol must be dosed higher than usually done in trials and in clinical practice to reach target serum levels.' MR. REINDERS

Gout patients have equal rates of success in attaining a serum urate concentration of 0.30 mmol/L or less—a value thought to predict good control of flares and a reduction of tophi—with either allopurinol or benzbromarone, as long as the doses are slightly higher than normal and based on serum urate values, according to the results of a randomized, open-label trial.

The data were presented at the annual meeting of the European League Against Rheumatism in Paris.

“In this small study, tolerability is not affected by doubling the dosage in patients not reaching target levels,” study investigator Mattheus Reinders, a hospital pharmacist at the Atrium Medisch Centrum, Heerlen (the Netherlands), said in an interview.

The results of the study make it clear that there is no difference in efficacy between allopurinol and benzbromarone when given in adequate doses, despite their different mechanisms of action. It also shows “allopurinol must be dosed higher than usually done in trials and in clinical practice [300 mg/day] to reach target serum levels,” Mr. Reinders said.

Gout flares and tophi mostly occur in those body parts with the lowest temperature: the extremities. It is often said that serum urate (uric acid) concentration—a well-accepted biomarker for evaluation of gout treatment—must be lower than the solubility at 37 °C (0.42 mmol/L) for good treatment.

But solubility drops dramatically with lower temperature, and so lower serum urate values are needed.

A serum urate concentration of 0.30 mmol/L or lower has been shown to be adequate in previous research, Mr. Reinders said in the interview.

EULAR's evidence-based recommendations for gout advise titrating the allopurinol dosage according to the level of serum urate that is attained. There is a lack of information about this approach and the effects of the higher dosages of serum urate-lowering drugs that will be required to decrease serum urate in patients who are not reaching target levels. Many clinicians also are prescribing only a fixed dosage of allopurinol 300 mg/day, he said.

Therefore, Mr. Reinders and his coinvestigators randomized 55 patients with newly diagnosed gout in an open-label trial comparing the efficacy and tolerability of allopurinol and benzbromarone. Allopurinol began at a dosage of 300 mg/day and was increased to 600 mg/day if necessary, while benzbromarone started at 100 mg/day and could be increased to 200 mg/day.

The gout diagnosis was confirmed by microscopic evidence of urate crystals in punctate from synovial fluid or periarticular structures or presence of tophi. The patients were indicated for serum urate-lowering treatment if they had tophi or more than two gout attacks per year. None of the patients had relevant liver or renal disease, and none had previously received either medication. Mr. Reinders conducted the research when he was in training at the Medisch Centrum Leeuwarden, also in the Netherlands, which funded the study.

After 2 months of treatment, a significantly greater percentage of patients who took benzbromarone 100 mg/day reached the target serum urate concentration of 0.30 mmol/L (13 of 25 patients, or 52%) than did patients who took allopurinol 300 mg/day (8 of 30 patients, or 27%).

After the investigators doubled the daily dosage of each drug in patients who had not met the treatment target, there was no significant difference in the total percentage of patients who had successful treatment with allopurinol (21 of 27, or 78%), compared with benzbromarone (18 of 23, or 78%).

Even before the dose increase, two patients stopped taking allopurinol and three stopped taking benzbromarone because of adverse drug reactions.

No more adverse reactions occurred after the dosages were increased in the nonresponders.

'Allopurinol must be dosed higher than usually done in trials and in clinical practice to reach target serum levels.' MR. REINDERS

OXON HILL, MD. — Obesity-related comorbidities are likely to improve or resolve in patients who undergo laparoscopic adjustable gastric banding after losing 20%–50% of their excess weight, according to a prospective study of patients with body mass indexes of 30–40 kg/m

The results indicate that even when less than 50% of excess weight is shed—which is often considered to be the cutoff for treatment failure—beneficial effects begin to occur, Samuel Sultan said at the annual meeting of the American Society for Metabolic and Bariatric Surgery.

Mr. Sultan and his coinvestigators in the department of surgery at New York University followed 50 patients for 2 years to determine the minimum percentage of excess weight loss that would provide the maximum probability of resolving or improving obesity-related comorbidities. Each patient had to have a history of obesity for at least 5 years as well as a history of failed attempts to lose weight by traditional methods.

All but one of the patients received the 9.5-cm band in the Lap-Band System. The patients' mean age was 47 years (ranging from 18 to 60 years), and most (96%) were women. The mean volume of saline added at each adjustment was 1.9 mL, according to Mr. Sultan, a medical student at the university.

After 2 years of prospective follow-up, losses of 20%–50% of excess weight provided the greatest probability of resolving or improving a variety of obesity-related comorbidities (see chart). At 2 years, 80% of all comorbidities had improved or resolved.

The patients' mean percentage of excess weight lost at 6 months was 41%, followed by 59% at 1 year and 61% at 2 years. Their body mass index dropped from a mean of 35 to 27 kg/m

Allergan Inc., which makes the Lap-Band System, funded the study. Some of the investigators have received honoraria for teaching and being on an advisory committee for Allergan.

ELSEVIER GLOBAL MEDICAL NEWS

OXON HILL, MD. — Obesity-related comorbidities are likely to improve or resolve in patients who undergo laparoscopic adjustable gastric banding after losing 20%–50% of their excess weight, according to a prospective study of patients with body mass indexes of 30–40 kg/m

The results indicate that even when less than 50% of excess weight is shed—which is often considered to be the cutoff for treatment failure—beneficial effects begin to occur, Samuel Sultan said at the annual meeting of the American Society for Metabolic and Bariatric Surgery.

Mr. Sultan and his coinvestigators in the department of surgery at New York University followed 50 patients for 2 years to determine the minimum percentage of excess weight loss that would provide the maximum probability of resolving or improving obesity-related comorbidities. Each patient had to have a history of obesity for at least 5 years as well as a history of failed attempts to lose weight by traditional methods.

All but one of the patients received the 9.5-cm band in the Lap-Band System. The patients' mean age was 47 years (ranging from 18 to 60 years), and most (96%) were women. The mean volume of saline added at each adjustment was 1.9 mL, according to Mr. Sultan, a medical student at the university.

After 2 years of prospective follow-up, losses of 20%–50% of excess weight provided the greatest probability of resolving or improving a variety of obesity-related comorbidities (see chart). At 2 years, 80% of all comorbidities had improved or resolved.

The patients' mean percentage of excess weight lost at 6 months was 41%, followed by 59% at 1 year and 61% at 2 years. Their body mass index dropped from a mean of 35 to 27 kg/m

Allergan Inc., which makes the Lap-Band System, funded the study. Some of the investigators have received honoraria for teaching and being on an advisory committee for Allergan.

ELSEVIER GLOBAL MEDICAL NEWS

OXON HILL, MD. — Obesity-related comorbidities are likely to improve or resolve in patients who undergo laparoscopic adjustable gastric banding after losing 20%–50% of their excess weight, according to a prospective study of patients with body mass indexes of 30–40 kg/m

The results indicate that even when less than 50% of excess weight is shed—which is often considered to be the cutoff for treatment failure—beneficial effects begin to occur, Samuel Sultan said at the annual meeting of the American Society for Metabolic and Bariatric Surgery.

Mr. Sultan and his coinvestigators in the department of surgery at New York University followed 50 patients for 2 years to determine the minimum percentage of excess weight loss that would provide the maximum probability of resolving or improving obesity-related comorbidities. Each patient had to have a history of obesity for at least 5 years as well as a history of failed attempts to lose weight by traditional methods.

All but one of the patients received the 9.5-cm band in the Lap-Band System. The patients' mean age was 47 years (ranging from 18 to 60 years), and most (96%) were women. The mean volume of saline added at each adjustment was 1.9 mL, according to Mr. Sultan, a medical student at the university.

After 2 years of prospective follow-up, losses of 20%–50% of excess weight provided the greatest probability of resolving or improving a variety of obesity-related comorbidities (see chart). At 2 years, 80% of all comorbidities had improved or resolved.

The patients' mean percentage of excess weight lost at 6 months was 41%, followed by 59% at 1 year and 61% at 2 years. Their body mass index dropped from a mean of 35 to 27 kg/m

Allergan Inc., which makes the Lap-Band System, funded the study. Some of the investigators have received honoraria for teaching and being on an advisory committee for Allergan.

ELSEVIER GLOBAL MEDICAL NEWS