Kerri Wachter

PITTSBURGH – Beta-blockers may have a protective effect in patients with traumatic brain injury, significantly reducing mortality, based on a retrospective study of more than 2,000 patients.

Although patients on beta-blockers in this study were older and more severely injured than were those not taking beta-blockers, mortality rates for the two groups were similar, Dr. Thomas J. Schroeppel said at the annual meeting of the American Association for the Surgery of Trauma. “This simple and inexpensive intervention may have a profound effect on outcome in these severely injured patients.”

Dr. Schroeppel and his coinvestigators reviewed the trauma registry at an urban level 1 trauma center for blunt traumatic brain injury (TBI) from January 2005 to December 2007. Patients who received at least one dose of beta-blockers were identified on the basis of the hospital pharmacy order database.

The researchers identified 2,601 patients with blunt TBI, of which 510 (19.6%) had received at least one dose of beta-blockers. The primary indication for beta-blocker use was hypertension. A total of 18% of patients were already on beta-blockers when they entered the hospital. There was no difference in mortality between patients already on beta-blockers at admission and those who got them afterward, according to Dr. Schroeppel, assistant professor of surgery at the University of Tennessee in Memphis.

Overall, the TBI patients were predominantly male (80%) with a mean age of 41 years, a mean admission Glasgow Coma Scale (GCS) of 11, and a mean Injury Severity Score (ISS) of 26. Overall mortality was 16%, Dr. Schroeppel said.

Patients on beta-blockers were significantly older (51 years vs. 38 years) and had significantly more severe head injury, measured by the head Abbreviated Injury Score (4.1 vs. 3.8) and the GCS (10 vs. 11). Significantly more patients on beta-blockers required transfusions than did the control group (66% vs. 27%). In addition, patients on beta-blockers had longer hospitals stays (28 days vs. 11 days) and nearly twice the incidence of ventilator-associated pneumonia, compared with the control group (48% vs. 27%).

Nonetheless, the 15% mortality rate among patients on beta-blockers was not significantly different from the 16% rate among controls.

Using multivariate logistic regression analysis to adjust for age, ISS, admission GCS, and transfusions, the researchers found that the use of beta-blockers was associated with an odds ratio for mortality of 0.36.

In subsequent analyses, the researchers excluded patients who died or had care withdrawn within the first 24-48 hours after admission in order to eliminate any potential survivor bias (i.e., only those who lived long enough received their beta-blockers). This showed a significant odds ratio for mortality of 0.37 in beta-blocker users. Likewise, after exclusion of patients who died or had care withdrawn within the first 24 hours, the patients taking beta-blockers had a significant 0.67 odds ratio for mortality. However, after the patients who died or had care withdrawn within the first 48 hours were excluded, the odds ratio for mortality was 0.77 with beta-blocker use, not a significant difference.

Catecholamine surge following TBI is associated with infectious morbidity and potentially preventable mortality. Previous studies have supported the protective effect of beta-adrenergic blockade in patients with TBI, which decreases cerebral metabolism, vasospasm, and oxygen consumption.

The researchers had hypothesized that suppression of the catecholamine surge in multiply injured TBI patients with beta-adrenergic blockade decreases mortality.

Dr. Schroeppel reported that he has no relevant financial relationships.

PITTSBURGH – Beta-blockers may have a protective effect in patients with traumatic brain injury, significantly reducing mortality, based on a retrospective study of more than 2,000 patients.

Although patients on beta-blockers in this study were older and more severely injured than were those not taking beta-blockers, mortality rates for the two groups were similar, Dr. Thomas J. Schroeppel said at the annual meeting of the American Association for the Surgery of Trauma. “This simple and inexpensive intervention may have a profound effect on outcome in these severely injured patients.”

Dr. Schroeppel and his coinvestigators reviewed the trauma registry at an urban level 1 trauma center for blunt traumatic brain injury (TBI) from January 2005 to December 2007. Patients who received at least one dose of beta-blockers were identified on the basis of the hospital pharmacy order database.

The researchers identified 2,601 patients with blunt TBI, of which 510 (19.6%) had received at least one dose of beta-blockers. The primary indication for beta-blocker use was hypertension. A total of 18% of patients were already on beta-blockers when they entered the hospital. There was no difference in mortality between patients already on beta-blockers at admission and those who got them afterward, according to Dr. Schroeppel, assistant professor of surgery at the University of Tennessee in Memphis.

Overall, the TBI patients were predominantly male (80%) with a mean age of 41 years, a mean admission Glasgow Coma Scale (GCS) of 11, and a mean Injury Severity Score (ISS) of 26. Overall mortality was 16%, Dr. Schroeppel said.

Patients on beta-blockers were significantly older (51 years vs. 38 years) and had significantly more severe head injury, measured by the head Abbreviated Injury Score (4.1 vs. 3.8) and the GCS (10 vs. 11). Significantly more patients on beta-blockers required transfusions than did the control group (66% vs. 27%). In addition, patients on beta-blockers had longer hospitals stays (28 days vs. 11 days) and nearly twice the incidence of ventilator-associated pneumonia, compared with the control group (48% vs. 27%).

Nonetheless, the 15% mortality rate among patients on beta-blockers was not significantly different from the 16% rate among controls.

Using multivariate logistic regression analysis to adjust for age, ISS, admission GCS, and transfusions, the researchers found that the use of beta-blockers was associated with an odds ratio for mortality of 0.36.

In subsequent analyses, the researchers excluded patients who died or had care withdrawn within the first 24-48 hours after admission in order to eliminate any potential survivor bias (i.e., only those who lived long enough received their beta-blockers). This showed a significant odds ratio for mortality of 0.37 in beta-blocker users. Likewise, after exclusion of patients who died or had care withdrawn within the first 24 hours, the patients taking beta-blockers had a significant 0.67 odds ratio for mortality. However, after the patients who died or had care withdrawn within the first 48 hours were excluded, the odds ratio for mortality was 0.77 with beta-blocker use, not a significant difference.

Catecholamine surge following TBI is associated with infectious morbidity and potentially preventable mortality. Previous studies have supported the protective effect of beta-adrenergic blockade in patients with TBI, which decreases cerebral metabolism, vasospasm, and oxygen consumption.

The researchers had hypothesized that suppression of the catecholamine surge in multiply injured TBI patients with beta-adrenergic blockade decreases mortality.

Dr. Schroeppel reported that he has no relevant financial relationships.

PITTSBURGH – Beta-blockers may have a protective effect in patients with traumatic brain injury, significantly reducing mortality, based on a retrospective study of more than 2,000 patients.

Although patients on beta-blockers in this study were older and more severely injured than were those not taking beta-blockers, mortality rates for the two groups were similar, Dr. Thomas J. Schroeppel said at the annual meeting of the American Association for the Surgery of Trauma. “This simple and inexpensive intervention may have a profound effect on outcome in these severely injured patients.”

Dr. Schroeppel and his coinvestigators reviewed the trauma registry at an urban level 1 trauma center for blunt traumatic brain injury (TBI) from January 2005 to December 2007. Patients who received at least one dose of beta-blockers were identified on the basis of the hospital pharmacy order database.

The researchers identified 2,601 patients with blunt TBI, of which 510 (19.6%) had received at least one dose of beta-blockers. The primary indication for beta-blocker use was hypertension. A total of 18% of patients were already on beta-blockers when they entered the hospital. There was no difference in mortality between patients already on beta-blockers at admission and those who got them afterward, according to Dr. Schroeppel, assistant professor of surgery at the University of Tennessee in Memphis.

Overall, the TBI patients were predominantly male (80%) with a mean age of 41 years, a mean admission Glasgow Coma Scale (GCS) of 11, and a mean Injury Severity Score (ISS) of 26. Overall mortality was 16%, Dr. Schroeppel said.

Patients on beta-blockers were significantly older (51 years vs. 38 years) and had significantly more severe head injury, measured by the head Abbreviated Injury Score (4.1 vs. 3.8) and the GCS (10 vs. 11). Significantly more patients on beta-blockers required transfusions than did the control group (66% vs. 27%). In addition, patients on beta-blockers had longer hospitals stays (28 days vs. 11 days) and nearly twice the incidence of ventilator-associated pneumonia, compared with the control group (48% vs. 27%).

Nonetheless, the 15% mortality rate among patients on beta-blockers was not significantly different from the 16% rate among controls.

Using multivariate logistic regression analysis to adjust for age, ISS, admission GCS, and transfusions, the researchers found that the use of beta-blockers was associated with an odds ratio for mortality of 0.36.

In subsequent analyses, the researchers excluded patients who died or had care withdrawn within the first 24-48 hours after admission in order to eliminate any potential survivor bias (i.e., only those who lived long enough received their beta-blockers). This showed a significant odds ratio for mortality of 0.37 in beta-blocker users. Likewise, after exclusion of patients who died or had care withdrawn within the first 24 hours, the patients taking beta-blockers had a significant 0.67 odds ratio for mortality. However, after the patients who died or had care withdrawn within the first 48 hours were excluded, the odds ratio for mortality was 0.77 with beta-blocker use, not a significant difference.

Catecholamine surge following TBI is associated with infectious morbidity and potentially preventable mortality. Previous studies have supported the protective effect of beta-adrenergic blockade in patients with TBI, which decreases cerebral metabolism, vasospasm, and oxygen consumption.

The researchers had hypothesized that suppression of the catecholamine surge in multiply injured TBI patients with beta-adrenergic blockade decreases mortality.

Dr. Schroeppel reported that he has no relevant financial relationships.

Among patients in Australia and New Zealand who were infected with 2009 influenza A(H1N1) during the winter season and developed acute respiratory distress syndrome, 79% of those who were treated with extracorporeal membrane oxygenation survived.

“Our findings have implications for health care planning and the clinical management of patients with 2009 influenza A(H1N1) during the 2009–2010 northern hemisphere winter,” wrote Dr. Andrew R. Davies of Monash University, Melbourne, and his colleagues (JAMA 2009 Oct. 12;doi:10.1001/JAMA.2009.1535). The study findings suggest that about 1,300 U.S. patients could need extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome related to 2009 H1N1 during the 2009–2010 winter season, the researchers said.

The study by the Australia and New Zealand Extracorporeal Membrane Oxygenation Influenza Investigators included all adult and pediatric patients who were treated with ECMO between June 1 and Aug. 31, 2009, in 15 ICUs in the two countries.

Of the 252 patients admitted with influenza to the participating ICUs, 201 received mechanical ventilation. The 68 patients who received ECMO had a mean age of 34 years; half were male and 61 had confirmed H1N1 infection. The most common comorbidities were obesity, asthma, and diabetes. Six patients were pregnant, and four were post partum. Three patients were younger than 15 years. Of the 68 ECMO patients, 48 survived to ICU discharge (32 were discharged from the hospital and 16 were still hospital inpatients), 14 (21%) died, and 6 remained in the ICU as of early September.

Among the 14 patients who died, the cause of death was intracranial hemorrhage (6 patients), other hemorrhage (4), and intractable respiratory failure (4). Of the 10 pregnant/postpartum patients, 7 survived. All three of the children treated with ECMO were alive, though one was still in the ICU.

During ECMO, hemorrhagic complications occurred in 54% of patients and infective complications in 62%.

“Our results indicate that the incidence of ARDS [acute respiratory distress syndrome] sufficient to warrant consideration of ECMO … exceeds 2.6 per million inhabitants” with confirmed or suspected 2009 influenza A(H1N1) during the winter season. When only confirmed cases were considered, the estimated incidence of ECMO use fell to 2.0 cases per million. In the preceding winter season, 0.15 cases per million were treated with ECMO for ARDS.

Compared with 133 patients with confirmed H1N1 who were treated with mechanical ventilation but not ECMO, those treated with ECMO had longer median durations of mechanical ventilation (18 days vs. 8 days), longer median ICU stays (22 vs. 12), and greater ICU mortality (14 vs. 12).

The authors had no relevant financial relationships.

Among patients in Australia and New Zealand who were infected with 2009 influenza A(H1N1) during the winter season and developed acute respiratory distress syndrome, 79% of those who were treated with extracorporeal membrane oxygenation survived.

“Our findings have implications for health care planning and the clinical management of patients with 2009 influenza A(H1N1) during the 2009–2010 northern hemisphere winter,” wrote Dr. Andrew R. Davies of Monash University, Melbourne, and his colleagues (JAMA 2009 Oct. 12;doi:10.1001/JAMA.2009.1535). The study findings suggest that about 1,300 U.S. patients could need extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome related to 2009 H1N1 during the 2009–2010 winter season, the researchers said.

The study by the Australia and New Zealand Extracorporeal Membrane Oxygenation Influenza Investigators included all adult and pediatric patients who were treated with ECMO between June 1 and Aug. 31, 2009, in 15 ICUs in the two countries.

Of the 252 patients admitted with influenza to the participating ICUs, 201 received mechanical ventilation. The 68 patients who received ECMO had a mean age of 34 years; half were male and 61 had confirmed H1N1 infection. The most common comorbidities were obesity, asthma, and diabetes. Six patients were pregnant, and four were post partum. Three patients were younger than 15 years. Of the 68 ECMO patients, 48 survived to ICU discharge (32 were discharged from the hospital and 16 were still hospital inpatients), 14 (21%) died, and 6 remained in the ICU as of early September.

Among the 14 patients who died, the cause of death was intracranial hemorrhage (6 patients), other hemorrhage (4), and intractable respiratory failure (4). Of the 10 pregnant/postpartum patients, 7 survived. All three of the children treated with ECMO were alive, though one was still in the ICU.

During ECMO, hemorrhagic complications occurred in 54% of patients and infective complications in 62%.

“Our results indicate that the incidence of ARDS [acute respiratory distress syndrome] sufficient to warrant consideration of ECMO … exceeds 2.6 per million inhabitants” with confirmed or suspected 2009 influenza A(H1N1) during the winter season. When only confirmed cases were considered, the estimated incidence of ECMO use fell to 2.0 cases per million. In the preceding winter season, 0.15 cases per million were treated with ECMO for ARDS.

Compared with 133 patients with confirmed H1N1 who were treated with mechanical ventilation but not ECMO, those treated with ECMO had longer median durations of mechanical ventilation (18 days vs. 8 days), longer median ICU stays (22 vs. 12), and greater ICU mortality (14 vs. 12).

The authors had no relevant financial relationships.

Among patients in Australia and New Zealand who were infected with 2009 influenza A(H1N1) during the winter season and developed acute respiratory distress syndrome, 79% of those who were treated with extracorporeal membrane oxygenation survived.

“Our findings have implications for health care planning and the clinical management of patients with 2009 influenza A(H1N1) during the 2009–2010 northern hemisphere winter,” wrote Dr. Andrew R. Davies of Monash University, Melbourne, and his colleagues (JAMA 2009 Oct. 12;doi:10.1001/JAMA.2009.1535). The study findings suggest that about 1,300 U.S. patients could need extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome related to 2009 H1N1 during the 2009–2010 winter season, the researchers said.

The study by the Australia and New Zealand Extracorporeal Membrane Oxygenation Influenza Investigators included all adult and pediatric patients who were treated with ECMO between June 1 and Aug. 31, 2009, in 15 ICUs in the two countries.

Of the 252 patients admitted with influenza to the participating ICUs, 201 received mechanical ventilation. The 68 patients who received ECMO had a mean age of 34 years; half were male and 61 had confirmed H1N1 infection. The most common comorbidities were obesity, asthma, and diabetes. Six patients were pregnant, and four were post partum. Three patients were younger than 15 years. Of the 68 ECMO patients, 48 survived to ICU discharge (32 were discharged from the hospital and 16 were still hospital inpatients), 14 (21%) died, and 6 remained in the ICU as of early September.

Among the 14 patients who died, the cause of death was intracranial hemorrhage (6 patients), other hemorrhage (4), and intractable respiratory failure (4). Of the 10 pregnant/postpartum patients, 7 survived. All three of the children treated with ECMO were alive, though one was still in the ICU.

During ECMO, hemorrhagic complications occurred in 54% of patients and infective complications in 62%.

“Our results indicate that the incidence of ARDS [acute respiratory distress syndrome] sufficient to warrant consideration of ECMO … exceeds 2.6 per million inhabitants” with confirmed or suspected 2009 influenza A(H1N1) during the winter season. When only confirmed cases were considered, the estimated incidence of ECMO use fell to 2.0 cases per million. In the preceding winter season, 0.15 cases per million were treated with ECMO for ARDS.

Compared with 133 patients with confirmed H1N1 who were treated with mechanical ventilation but not ECMO, those treated with ECMO had longer median durations of mechanical ventilation (18 days vs. 8 days), longer median ICU stays (22 vs. 12), and greater ICU mortality (14 vs. 12).

The authors had no relevant financial relationships.

DENVER — Patients with rheumatic diseases who were on long-term glucocorticoid therapy were almost twice as likely to have low bone mass as were those with a rheumatic disease who were not on glucocorticoids, based on the results of a study of more than 200,000 patients with rheumatic diseases.

The findings were presented as a poster at the annual meeting of the American Society for Bone and Mineral Research by Dr. Viviana A. Reidel and her coinvestigators.

The researchers used UnitedHealth Group Inc.'s proprietary normative health information database of medical claims—both private and Medicare/Medicaid. In 2007, the database included information on 23.6 million people.

The researchers identified adults who had had at least two visits resulting in an ICD-9-CM code for a rheumatic disease and an ICD-9-CM code for either osteoporosis or osteopenia occurring after the first prescription of a glucocorticoid.

Long-term use of a glucocorticoid was defined as one or more monthly prescriptions for at least 6 months. High-dose glucocorticoids were defined as a prednisone dosage of at least 7.5 mg/day, or the equivalent; low-dose glucocorticoid use was defined as a prednisone dosage of less than 7.5 mg/day, or the equivalent. The nonglucocorticoid group included patients with rheumatic diseases who were prescribed any other therapy or no therapy.

In all, 201,121 patients with rheumatic diseases were identified. The most common disease was rheumatoid arthritis (57%), followed by systemic lupus erythematosus, spondyloarthropathies, polymyalgia rheumatica, vasculitis, and enteropathic arthritis. (See box.) Among those with long-term glucocorticoid use, 44% of women and 11% of men had low bone mineral density. Among those who were not long-term users, 31% of women and 4% of men had low BMD.

Patients with rheumatic diseases who were on long-term glucocorticoids had a relative risk of 1.7 of having low bone mass, compared with those with a rheumatic disease who were not on glucocorticoids. “However, our analysis suggests that the effect of long-term higher-dose glucocorticoid treatment on increasing risk of glucocorticoid-induced low bone mass compared to long-term lower-dose glucocorticoid treatment is weak,” wrote Dr. Reidel, who is the medical director at i3 Research, a clinical research company. There was a slight but significantly increased risk of low bone mass in patients who were treated long term with high-dose glucocorticoids, compared with those treated long term with low doses (odds ratio, 1.1).

Among patients with bisphosphonate use, there was no significant difference in risk of low bone mass between those on long-term glucocorticoid use and those without.

The researchers also found that only 0.2% of patients with long-term glucocorticoid use had at least one dual-energy x-ray absorptiometry scan, compared with 8% of those with no known glucocorticoid exposure. “Patients with low bone mass–associated rheumatic diseases on long-term glucocorticoids are not being systematically assessed with BMD measurements, despite the recommendations of published guidelines.”

Source Elsevier Global Medical News

DENVER — Patients with rheumatic diseases who were on long-term glucocorticoid therapy were almost twice as likely to have low bone mass as were those with a rheumatic disease who were not on glucocorticoids, based on the results of a study of more than 200,000 patients with rheumatic diseases.

The findings were presented as a poster at the annual meeting of the American Society for Bone and Mineral Research by Dr. Viviana A. Reidel and her coinvestigators.

The researchers used UnitedHealth Group Inc.'s proprietary normative health information database of medical claims—both private and Medicare/Medicaid. In 2007, the database included information on 23.6 million people.

The researchers identified adults who had had at least two visits resulting in an ICD-9-CM code for a rheumatic disease and an ICD-9-CM code for either osteoporosis or osteopenia occurring after the first prescription of a glucocorticoid.

Long-term use of a glucocorticoid was defined as one or more monthly prescriptions for at least 6 months. High-dose glucocorticoids were defined as a prednisone dosage of at least 7.5 mg/day, or the equivalent; low-dose glucocorticoid use was defined as a prednisone dosage of less than 7.5 mg/day, or the equivalent. The nonglucocorticoid group included patients with rheumatic diseases who were prescribed any other therapy or no therapy.

In all, 201,121 patients with rheumatic diseases were identified. The most common disease was rheumatoid arthritis (57%), followed by systemic lupus erythematosus, spondyloarthropathies, polymyalgia rheumatica, vasculitis, and enteropathic arthritis. (See box.) Among those with long-term glucocorticoid use, 44% of women and 11% of men had low bone mineral density. Among those who were not long-term users, 31% of women and 4% of men had low BMD.

Patients with rheumatic diseases who were on long-term glucocorticoids had a relative risk of 1.7 of having low bone mass, compared with those with a rheumatic disease who were not on glucocorticoids. “However, our analysis suggests that the effect of long-term higher-dose glucocorticoid treatment on increasing risk of glucocorticoid-induced low bone mass compared to long-term lower-dose glucocorticoid treatment is weak,” wrote Dr. Reidel, who is the medical director at i3 Research, a clinical research company. There was a slight but significantly increased risk of low bone mass in patients who were treated long term with high-dose glucocorticoids, compared with those treated long term with low doses (odds ratio, 1.1).

Among patients with bisphosphonate use, there was no significant difference in risk of low bone mass between those on long-term glucocorticoid use and those without.

The researchers also found that only 0.2% of patients with long-term glucocorticoid use had at least one dual-energy x-ray absorptiometry scan, compared with 8% of those with no known glucocorticoid exposure. “Patients with low bone mass–associated rheumatic diseases on long-term glucocorticoids are not being systematically assessed with BMD measurements, despite the recommendations of published guidelines.”

Source Elsevier Global Medical News

DENVER — Patients with rheumatic diseases who were on long-term glucocorticoid therapy were almost twice as likely to have low bone mass as were those with a rheumatic disease who were not on glucocorticoids, based on the results of a study of more than 200,000 patients with rheumatic diseases.

The findings were presented as a poster at the annual meeting of the American Society for Bone and Mineral Research by Dr. Viviana A. Reidel and her coinvestigators.

The researchers used UnitedHealth Group Inc.'s proprietary normative health information database of medical claims—both private and Medicare/Medicaid. In 2007, the database included information on 23.6 million people.

The researchers identified adults who had had at least two visits resulting in an ICD-9-CM code for a rheumatic disease and an ICD-9-CM code for either osteoporosis or osteopenia occurring after the first prescription of a glucocorticoid.

Long-term use of a glucocorticoid was defined as one or more monthly prescriptions for at least 6 months. High-dose glucocorticoids were defined as a prednisone dosage of at least 7.5 mg/day, or the equivalent; low-dose glucocorticoid use was defined as a prednisone dosage of less than 7.5 mg/day, or the equivalent. The nonglucocorticoid group included patients with rheumatic diseases who were prescribed any other therapy or no therapy.

In all, 201,121 patients with rheumatic diseases were identified. The most common disease was rheumatoid arthritis (57%), followed by systemic lupus erythematosus, spondyloarthropathies, polymyalgia rheumatica, vasculitis, and enteropathic arthritis. (See box.) Among those with long-term glucocorticoid use, 44% of women and 11% of men had low bone mineral density. Among those who were not long-term users, 31% of women and 4% of men had low BMD.

Patients with rheumatic diseases who were on long-term glucocorticoids had a relative risk of 1.7 of having low bone mass, compared with those with a rheumatic disease who were not on glucocorticoids. “However, our analysis suggests that the effect of long-term higher-dose glucocorticoid treatment on increasing risk of glucocorticoid-induced low bone mass compared to long-term lower-dose glucocorticoid treatment is weak,” wrote Dr. Reidel, who is the medical director at i3 Research, a clinical research company. There was a slight but significantly increased risk of low bone mass in patients who were treated long term with high-dose glucocorticoids, compared with those treated long term with low doses (odds ratio, 1.1).

Among patients with bisphosphonate use, there was no significant difference in risk of low bone mass between those on long-term glucocorticoid use and those without.

The researchers also found that only 0.2% of patients with long-term glucocorticoid use had at least one dual-energy x-ray absorptiometry scan, compared with 8% of those with no known glucocorticoid exposure. “Patients with low bone mass–associated rheumatic diseases on long-term glucocorticoids are not being systematically assessed with BMD measurements, despite the recommendations of published guidelines.”

Source Elsevier Global Medical News

DENVER — The FRAX 10-year fracture risk tool was fairly accurate in predicting the observed number of hip fractures that occurred among more than 5,000 participants of the Framingham Heart Study, according to data presented as a poster at the annual meeting of the American Society for Bone and Mineral Research.

The 10-year observed incidence of hip fracture for women was 117 cases, which did not differ significantly from the FRAX predicted number of 113. For men, the observed incidence was 29 cases, also not significantly different from the FRAX predicted number of 38, reported Elizabeth J. Samelson, Ph.D., of the Institute for Aging Research in Boston, and her coinvestigators.

FRAX is an online tool that was developed by the World Health Organization to calculate the 10-year probability of hip fracture and major osteoporotic fracture in women and men, aged 40–90 years, on the basis of bone mineral density (BMD), sex, age, smoking status, glucocorticoid use, height and weight, diagnosis of rheumatoid arthritis or secondary osteoporosis, history of fracture, and parental history of fracture. FRAX was developed using several population-based cohorts.

This study included 5,204 Framingham cohort members (2,917 women and 2,287 men) who had a baseline examination in 1987–2001 and were followed for hip fracture over 10 years. All were white. At baseline, patients were assessed for age, body mass index, current smoking status, alcohol consumption, glucocorticoid use, diagnosis of rheumatoid arthritis, prior fragility fracture, parental history of fracture, and T score. History of parental hip fracture was not available for members of the original cohort (1,456); these participants were classified as having no parental history of hip fracture. Femoral neck BMD was available for 4,224 participants.

The researchers used FRAX version 3.0 to calculate the 10-year probability of hip fracture and compared the expected number with the number observed in the cohort. A hip fracture was defined as a proximal femur fracture and was confirmed by review of medical records (including radiographic and surgical reports). Data were further analyzed by age and sex.

Among women aged 40–75 years, the incidence was 52 cases, compared with 57 expected by FRAX; among men aged 40–75 years, the incidence was 12 cases, compared with 23 expected by FRAX. Notably, the observed probability of hip fracture in the oldest adults (aged 76–90 years) exceeded the number predicted by FRAX, while the opposite was true for those aged 40–75. However, these differences were not significant, the authors noted. Among women aged 76–90 years, the incidence was 65 cases, compared with 55 expected by FRAX; among men aged 76–90 years, the incidence was 17 cases, compared with 14 expected by FRAX.

FRAX can be useful to communicate osteoporosis risk in white U.S. adults in the clinical or public health setting; “however, the tool may overestimate hip fracture risk in persons aged 40–75 years,” the researchers wrote.

The latest version of FRAX can be accessed at www.shef.ac.uk/FRAX

A related video is at www.youtube.com/InternalMedicineNews

DENVER — The FRAX 10-year fracture risk tool was fairly accurate in predicting the observed number of hip fractures that occurred among more than 5,000 participants of the Framingham Heart Study, according to data presented as a poster at the annual meeting of the American Society for Bone and Mineral Research.

The 10-year observed incidence of hip fracture for women was 117 cases, which did not differ significantly from the FRAX predicted number of 113. For men, the observed incidence was 29 cases, also not significantly different from the FRAX predicted number of 38, reported Elizabeth J. Samelson, Ph.D., of the Institute for Aging Research in Boston, and her coinvestigators.

FRAX is an online tool that was developed by the World Health Organization to calculate the 10-year probability of hip fracture and major osteoporotic fracture in women and men, aged 40–90 years, on the basis of bone mineral density (BMD), sex, age, smoking status, glucocorticoid use, height and weight, diagnosis of rheumatoid arthritis or secondary osteoporosis, history of fracture, and parental history of fracture. FRAX was developed using several population-based cohorts.

This study included 5,204 Framingham cohort members (2,917 women and 2,287 men) who had a baseline examination in 1987–2001 and were followed for hip fracture over 10 years. All were white. At baseline, patients were assessed for age, body mass index, current smoking status, alcohol consumption, glucocorticoid use, diagnosis of rheumatoid arthritis, prior fragility fracture, parental history of fracture, and T score. History of parental hip fracture was not available for members of the original cohort (1,456); these participants were classified as having no parental history of hip fracture. Femoral neck BMD was available for 4,224 participants.

The researchers used FRAX version 3.0 to calculate the 10-year probability of hip fracture and compared the expected number with the number observed in the cohort. A hip fracture was defined as a proximal femur fracture and was confirmed by review of medical records (including radiographic and surgical reports). Data were further analyzed by age and sex.

Among women aged 40–75 years, the incidence was 52 cases, compared with 57 expected by FRAX; among men aged 40–75 years, the incidence was 12 cases, compared with 23 expected by FRAX. Notably, the observed probability of hip fracture in the oldest adults (aged 76–90 years) exceeded the number predicted by FRAX, while the opposite was true for those aged 40–75. However, these differences were not significant, the authors noted. Among women aged 76–90 years, the incidence was 65 cases, compared with 55 expected by FRAX; among men aged 76–90 years, the incidence was 17 cases, compared with 14 expected by FRAX.

FRAX can be useful to communicate osteoporosis risk in white U.S. adults in the clinical or public health setting; “however, the tool may overestimate hip fracture risk in persons aged 40–75 years,” the researchers wrote.

The latest version of FRAX can be accessed at www.shef.ac.uk/FRAX

A related video is at www.youtube.com/InternalMedicineNews

DENVER — The FRAX 10-year fracture risk tool was fairly accurate in predicting the observed number of hip fractures that occurred among more than 5,000 participants of the Framingham Heart Study, according to data presented as a poster at the annual meeting of the American Society for Bone and Mineral Research.

The 10-year observed incidence of hip fracture for women was 117 cases, which did not differ significantly from the FRAX predicted number of 113. For men, the observed incidence was 29 cases, also not significantly different from the FRAX predicted number of 38, reported Elizabeth J. Samelson, Ph.D., of the Institute for Aging Research in Boston, and her coinvestigators.

FRAX is an online tool that was developed by the World Health Organization to calculate the 10-year probability of hip fracture and major osteoporotic fracture in women and men, aged 40–90 years, on the basis of bone mineral density (BMD), sex, age, smoking status, glucocorticoid use, height and weight, diagnosis of rheumatoid arthritis or secondary osteoporosis, history of fracture, and parental history of fracture. FRAX was developed using several population-based cohorts.

This study included 5,204 Framingham cohort members (2,917 women and 2,287 men) who had a baseline examination in 1987–2001 and were followed for hip fracture over 10 years. All were white. At baseline, patients were assessed for age, body mass index, current smoking status, alcohol consumption, glucocorticoid use, diagnosis of rheumatoid arthritis, prior fragility fracture, parental history of fracture, and T score. History of parental hip fracture was not available for members of the original cohort (1,456); these participants were classified as having no parental history of hip fracture. Femoral neck BMD was available for 4,224 participants.

The researchers used FRAX version 3.0 to calculate the 10-year probability of hip fracture and compared the expected number with the number observed in the cohort. A hip fracture was defined as a proximal femur fracture and was confirmed by review of medical records (including radiographic and surgical reports). Data were further analyzed by age and sex.

Among women aged 40–75 years, the incidence was 52 cases, compared with 57 expected by FRAX; among men aged 40–75 years, the incidence was 12 cases, compared with 23 expected by FRAX. Notably, the observed probability of hip fracture in the oldest adults (aged 76–90 years) exceeded the number predicted by FRAX, while the opposite was true for those aged 40–75. However, these differences were not significant, the authors noted. Among women aged 76–90 years, the incidence was 65 cases, compared with 55 expected by FRAX; among men aged 76–90 years, the incidence was 17 cases, compared with 14 expected by FRAX.

FRAX can be useful to communicate osteoporosis risk in white U.S. adults in the clinical or public health setting; “however, the tool may overestimate hip fracture risk in persons aged 40–75 years,” the researchers wrote.

The latest version of FRAX can be accessed at www.shef.ac.uk/FRAX

A related video is at www.youtube.com/InternalMedicineNews

DENVER — People on long-term glucocorticoids have a significant risk for fracture at relatively high bone mineral density T scores, a finding that may lead to changes in the management of such patients.

“In glucocorticoid osteoporosis, the fracture risk seems to take off quite dramatically somewhere around T scores of −1.5,” Dr. Philip Sambrook said at the annual meeting of the American Society for Bone and Mineral Research. “Most of the guidelines around the world are now suggesting that the intervention threshold [for those on glucocorticoids] should be [a T score of] about −1.5.”

Patients on glucocorticoids typically have midline fractures of the vertebrae, where the bone just collapses in the middle of the vertebra. “This is different from the anterior wedge fracture that occurs most commonly in postmenopausal women with osteoporosis,” noted Dr. Nancy Lane, director of the center for healthy aging at the University of California, Davis. This is because there are some differences in how bones become fragile in the presence of glucocorticoids, she said.

Dr. Sambrook, of Royal North Shore Hospital in Sydney and head of the bone and joint group at the Kolling Institute of Medical Research, presented cases that “really illustrate the type of patients that we often struggle with.”

Patient No. 1

A 66-year-old woman was recently diagnosed with polymyalgia rheumatica. She had been started on 25 mg/day prednisone and the disease activity lessened in response. Her history included chronic atopic dermatitis and hypothyroidism. She had no other medical problems. There was no family history of hip fracture. She did not smoke or drink. She had a slightly early menopause but had not used hormone therapy. She reported eating one or two servings of dairy products daily. She also considered herself to be physically active, although she had no formal exercise program.

In her work-up, a spine x-ray showed a vertebral compression. Bone mineral density (BMD) measurements showed modest osteopenia (T scores of −1.5 at the spine and −1.6 at the hip). She had normal levels of calcium and parathyroid hormone (PTH). Her vitamin D level was equivocal, however. Her thyroid function was normal.

This patient had modest osteopenia at the time of her diagnosis. Once she was started on glucocorticoids, her T scores could have fallen rapidly and then stabilized over time, without treatment for bone loss, Dr. Sambrook said. “As she becomes established on glucocorticoids, she will perhaps not lose that much bone,” but she's at risk of fracture.

When clinical trial data are interpreted, it's important to keep two clinical scenarios in mind: prevention (when initial rapid loss of bone is to be avoided) and treatment (when the patient is on chronic glucocorticoids and may not be losing a lot of bone but is still at risk for fracture).

“Most of us would believe that vitamin D [plus] calcium is an adjunctive therapy,” Dr. Sambrook said. The data appear to back that up. In a 1996 trial, patients with glucocorticoid osteoporosis were randomized to 50,000 U/week of vitamin D plus 1,000 mg/day of calcium, or placebo. Both groups lost bone at the spine quite rapidly, although there was a trend for patients on vitamin D and calcium to do slightly better (J. Rheumatol. 1996;23:995–1000).

In another study, researchers demonstrated that daily alendronate increases bone density in patients who receive glucocorticoids, compared with those on placebo (N. Engl. J. Med. 1998;339:292–9). Similar results have been demonstrated with etidronate, risedronate, and zoledronic acid.

Dr. Sambrook recommended that the patient receive calcium and vitamin D supplementation. Also, “we would primarily give her bisphosphonates until prednisone is discontinued” and possibly beyond, depending on her overall fracture risk after prednisone treatment.

Patient No. 2

A 24-year-old woman has had systemic lupus erythematosus for 3 years, which is now severe. Her SLE complications have included encephalitis, vasculitis, renal involvement, and deep vein thrombosis. She had no family history of osteoporosis. She did not consume much dietary calcium, but claimed to get adequate sun exposure. She had been on an oral contraceptive since the age of 17. Her appetite and weight were average and stable.

At the time of her presentation, she had been on prednisone for 6 months, with dosages averaging 25–50 mg daily. However, the recent onset of renal complications required increasing the dose to 75 mg daily. She was also taking an antimalaria drug. Her vitamin D level was equivocal and needed to be addressed. She had normal calcium and PTH levels and normal thyroid function. However, her spine T score was −1.4 and her hip T score was −1.0.

Dr. Sambrook's concern was the effect of bisphosphonates on fetal development. The patient was not pregnant, but might have become so intentionally or unintentionally. Bisphosphonates are classified as pregnancy category C drugs by the Food and Drug Administration, meaning that they are contraindicated in pregnancy.

One approach to managing this patient is to simply watch her and measure BMD in 12 months. Another is to use a bisphosphonate in conjunction with vitamin D and calcium supplementation. Risedronate might be the better choice, given its quicker onset and offset of action, he said.

“As long as she stayed on prednisone, I might not be as aggressive as with postmenopausal women,” Dr. Sambrook noted. If the prednisone dose was decreased, he said that he might consider stopping bisphosphonate treatment.

Dr. Lane and Dr. Sambrook both reported financial relationships with several pharmaceutical companies.

A whole-body dual-energy x-ray absorptiometry scan can provide information on total and regional BMD (left) and body composition (fat, muscle mass).

Source ©Elsevier

DENVER — People on long-term glucocorticoids have a significant risk for fracture at relatively high bone mineral density T scores, a finding that may lead to changes in the management of such patients.

“In glucocorticoid osteoporosis, the fracture risk seems to take off quite dramatically somewhere around T scores of −1.5,” Dr. Philip Sambrook said at the annual meeting of the American Society for Bone and Mineral Research. “Most of the guidelines around the world are now suggesting that the intervention threshold [for those on glucocorticoids] should be [a T score of] about −1.5.”

Patients on glucocorticoids typically have midline fractures of the vertebrae, where the bone just collapses in the middle of the vertebra. “This is different from the anterior wedge fracture that occurs most commonly in postmenopausal women with osteoporosis,” noted Dr. Nancy Lane, director of the center for healthy aging at the University of California, Davis. This is because there are some differences in how bones become fragile in the presence of glucocorticoids, she said.

Dr. Sambrook, of Royal North Shore Hospital in Sydney and head of the bone and joint group at the Kolling Institute of Medical Research, presented cases that “really illustrate the type of patients that we often struggle with.”

Patient No. 1

A 66-year-old woman was recently diagnosed with polymyalgia rheumatica. She had been started on 25 mg/day prednisone and the disease activity lessened in response. Her history included chronic atopic dermatitis and hypothyroidism. She had no other medical problems. There was no family history of hip fracture. She did not smoke or drink. She had a slightly early menopause but had not used hormone therapy. She reported eating one or two servings of dairy products daily. She also considered herself to be physically active, although she had no formal exercise program.

In her work-up, a spine x-ray showed a vertebral compression. Bone mineral density (BMD) measurements showed modest osteopenia (T scores of −1.5 at the spine and −1.6 at the hip). She had normal levels of calcium and parathyroid hormone (PTH). Her vitamin D level was equivocal, however. Her thyroid function was normal.

This patient had modest osteopenia at the time of her diagnosis. Once she was started on glucocorticoids, her T scores could have fallen rapidly and then stabilized over time, without treatment for bone loss, Dr. Sambrook said. “As she becomes established on glucocorticoids, she will perhaps not lose that much bone,” but she's at risk of fracture.

When clinical trial data are interpreted, it's important to keep two clinical scenarios in mind: prevention (when initial rapid loss of bone is to be avoided) and treatment (when the patient is on chronic glucocorticoids and may not be losing a lot of bone but is still at risk for fracture).

“Most of us would believe that vitamin D [plus] calcium is an adjunctive therapy,” Dr. Sambrook said. The data appear to back that up. In a 1996 trial, patients with glucocorticoid osteoporosis were randomized to 50,000 U/week of vitamin D plus 1,000 mg/day of calcium, or placebo. Both groups lost bone at the spine quite rapidly, although there was a trend for patients on vitamin D and calcium to do slightly better (J. Rheumatol. 1996;23:995–1000).

In another study, researchers demonstrated that daily alendronate increases bone density in patients who receive glucocorticoids, compared with those on placebo (N. Engl. J. Med. 1998;339:292–9). Similar results have been demonstrated with etidronate, risedronate, and zoledronic acid.

Dr. Sambrook recommended that the patient receive calcium and vitamin D supplementation. Also, “we would primarily give her bisphosphonates until prednisone is discontinued” and possibly beyond, depending on her overall fracture risk after prednisone treatment.

Patient No. 2

A 24-year-old woman has had systemic lupus erythematosus for 3 years, which is now severe. Her SLE complications have included encephalitis, vasculitis, renal involvement, and deep vein thrombosis. She had no family history of osteoporosis. She did not consume much dietary calcium, but claimed to get adequate sun exposure. She had been on an oral contraceptive since the age of 17. Her appetite and weight were average and stable.

At the time of her presentation, she had been on prednisone for 6 months, with dosages averaging 25–50 mg daily. However, the recent onset of renal complications required increasing the dose to 75 mg daily. She was also taking an antimalaria drug. Her vitamin D level was equivocal and needed to be addressed. She had normal calcium and PTH levels and normal thyroid function. However, her spine T score was −1.4 and her hip T score was −1.0.

Dr. Sambrook's concern was the effect of bisphosphonates on fetal development. The patient was not pregnant, but might have become so intentionally or unintentionally. Bisphosphonates are classified as pregnancy category C drugs by the Food and Drug Administration, meaning that they are contraindicated in pregnancy.

One approach to managing this patient is to simply watch her and measure BMD in 12 months. Another is to use a bisphosphonate in conjunction with vitamin D and calcium supplementation. Risedronate might be the better choice, given its quicker onset and offset of action, he said.

“As long as she stayed on prednisone, I might not be as aggressive as with postmenopausal women,” Dr. Sambrook noted. If the prednisone dose was decreased, he said that he might consider stopping bisphosphonate treatment.

Dr. Lane and Dr. Sambrook both reported financial relationships with several pharmaceutical companies.

A whole-body dual-energy x-ray absorptiometry scan can provide information on total and regional BMD (left) and body composition (fat, muscle mass).

Source ©Elsevier

DENVER — People on long-term glucocorticoids have a significant risk for fracture at relatively high bone mineral density T scores, a finding that may lead to changes in the management of such patients.

“In glucocorticoid osteoporosis, the fracture risk seems to take off quite dramatically somewhere around T scores of −1.5,” Dr. Philip Sambrook said at the annual meeting of the American Society for Bone and Mineral Research. “Most of the guidelines around the world are now suggesting that the intervention threshold [for those on glucocorticoids] should be [a T score of] about −1.5.”

Patients on glucocorticoids typically have midline fractures of the vertebrae, where the bone just collapses in the middle of the vertebra. “This is different from the anterior wedge fracture that occurs most commonly in postmenopausal women with osteoporosis,” noted Dr. Nancy Lane, director of the center for healthy aging at the University of California, Davis. This is because there are some differences in how bones become fragile in the presence of glucocorticoids, she said.

Dr. Sambrook, of Royal North Shore Hospital in Sydney and head of the bone and joint group at the Kolling Institute of Medical Research, presented cases that “really illustrate the type of patients that we often struggle with.”

Patient No. 1

A 66-year-old woman was recently diagnosed with polymyalgia rheumatica. She had been started on 25 mg/day prednisone and the disease activity lessened in response. Her history included chronic atopic dermatitis and hypothyroidism. She had no other medical problems. There was no family history of hip fracture. She did not smoke or drink. She had a slightly early menopause but had not used hormone therapy. She reported eating one or two servings of dairy products daily. She also considered herself to be physically active, although she had no formal exercise program.

In her work-up, a spine x-ray showed a vertebral compression. Bone mineral density (BMD) measurements showed modest osteopenia (T scores of −1.5 at the spine and −1.6 at the hip). She had normal levels of calcium and parathyroid hormone (PTH). Her vitamin D level was equivocal, however. Her thyroid function was normal.

This patient had modest osteopenia at the time of her diagnosis. Once she was started on glucocorticoids, her T scores could have fallen rapidly and then stabilized over time, without treatment for bone loss, Dr. Sambrook said. “As she becomes established on glucocorticoids, she will perhaps not lose that much bone,” but she's at risk of fracture.

When clinical trial data are interpreted, it's important to keep two clinical scenarios in mind: prevention (when initial rapid loss of bone is to be avoided) and treatment (when the patient is on chronic glucocorticoids and may not be losing a lot of bone but is still at risk for fracture).

“Most of us would believe that vitamin D [plus] calcium is an adjunctive therapy,” Dr. Sambrook said. The data appear to back that up. In a 1996 trial, patients with glucocorticoid osteoporosis were randomized to 50,000 U/week of vitamin D plus 1,000 mg/day of calcium, or placebo. Both groups lost bone at the spine quite rapidly, although there was a trend for patients on vitamin D and calcium to do slightly better (J. Rheumatol. 1996;23:995–1000).

In another study, researchers demonstrated that daily alendronate increases bone density in patients who receive glucocorticoids, compared with those on placebo (N. Engl. J. Med. 1998;339:292–9). Similar results have been demonstrated with etidronate, risedronate, and zoledronic acid.

Dr. Sambrook recommended that the patient receive calcium and vitamin D supplementation. Also, “we would primarily give her bisphosphonates until prednisone is discontinued” and possibly beyond, depending on her overall fracture risk after prednisone treatment.

Patient No. 2

A 24-year-old woman has had systemic lupus erythematosus for 3 years, which is now severe. Her SLE complications have included encephalitis, vasculitis, renal involvement, and deep vein thrombosis. She had no family history of osteoporosis. She did not consume much dietary calcium, but claimed to get adequate sun exposure. She had been on an oral contraceptive since the age of 17. Her appetite and weight were average and stable.

At the time of her presentation, she had been on prednisone for 6 months, with dosages averaging 25–50 mg daily. However, the recent onset of renal complications required increasing the dose to 75 mg daily. She was also taking an antimalaria drug. Her vitamin D level was equivocal and needed to be addressed. She had normal calcium and PTH levels and normal thyroid function. However, her spine T score was −1.4 and her hip T score was −1.0.

Dr. Sambrook's concern was the effect of bisphosphonates on fetal development. The patient was not pregnant, but might have become so intentionally or unintentionally. Bisphosphonates are classified as pregnancy category C drugs by the Food and Drug Administration, meaning that they are contraindicated in pregnancy.

One approach to managing this patient is to simply watch her and measure BMD in 12 months. Another is to use a bisphosphonate in conjunction with vitamin D and calcium supplementation. Risedronate might be the better choice, given its quicker onset and offset of action, he said.

“As long as she stayed on prednisone, I might not be as aggressive as with postmenopausal women,” Dr. Sambrook noted. If the prednisone dose was decreased, he said that he might consider stopping bisphosphonate treatment.

Dr. Lane and Dr. Sambrook both reported financial relationships with several pharmaceutical companies.

A whole-body dual-energy x-ray absorptiometry scan can provide information on total and regional BMD (left) and body composition (fat, muscle mass).

Source ©Elsevier

DENVER — Extended physiotherapy significantly reduced the rate of falls among patients with a prior hip fracture, and high-dose vitamin D significantly reduced the rate of hospital readmissions in a study of 173 patients.

A program of extended physiotherapy reduced the fall rate by 25%, compared with standard postfracture physiotherapy; high-dose vitamin D therapy reduced the hospital readmission rate by 39%, compared with a lower dose, the researchers found.

“The extended physiotherapy program, together with 2,000 IU vitamin D, has complementary benefits on post–hip fracture care,” Dr. Heike Bischoff-Ferrari said at the annual meeting of the American Society for Bone and Mineral Research.

The researchers enrolled 173 patients after their first acute hip fracture. Of these, most (79%) were women. Their mean age was 84 years, and 77% were living in the community. Half (51%) of the patients had severe vitamin D deficiency with serum 25-hydroxyvitamin D levels below 30 nmol/L; almost all (98%) had serum 25-hydroxyvitamin D levels below 75 nmol/L.

Patients were randomized to receive extended physiotherapy or standard physiotherapy. Extended physiotherapy consisted of supervised therapy for 1 hour per day during acute care, plus an unsupervised home program of exercises to perform regularly for 1 year. The standard therapy consisted of supervised therapy for 30 minutes per day during acute care.

Patients were also randomized to receive vitamin D supplementation at 2,000 IU or 800 IU vitamin D₃ per day. All patients received calcium.

Clinical assessment, which included laboratory tests and functional evaluations, took place at baseline and at 6 and 12 months' follow-up. Falls and readmissions were assessed by monthly calls to patients, patient calls to a hotline, and patient diaries.

The primary end point was the rate of falls over 12 months. The secondary end point was the rate of hospital readmission over 12 months.

In all, 86 participants were included in the high-dose vitamin D group and 87 in the lower-dose group; 87 participants were included in the extensive physiotherapy group, and 86 in the regular physiotherapy group. The groups did not differ by age, gender, BMI, cognitive function, baseline 25-hydroxyvitamin D levels, and Charleston Comorbidity Index scores.

The researchers documented 212 falls in 92 participants. Of these, 41% fell once, 26% fell twice, 19% fell three times, and 14% fell more than three times. The rate of falls per patient-year was 1.43. There were 22 new nonvertebral fractures, 9 of which were in the contralateral hip.

In terms of hospital readmissions, there were 74 readmissions among 54 participants. Of these, 72% had one readmission, 20% had two, and 8% had three. The rate of hospital readmission was 50%.

Extended physiotherapy reduced the rate of falls by 25%, compared with regular physiotherapy, a significant reduction. Similar improvements were seen in function. However, extended physiotherapy did not reduce the rate of hospital readmissions.

There was no difference in the fall rate for the two vitamin D groups, but high-dose vitamin D did reduce the rate of hospital readmission by 39%, which was significant. There was also a significant 60% reduction in fall-related injuries. “This was mainly driven by a nonsignificant reduction in repeat nonvertebral fractures by 52%,” said Dr. Bischoff-Ferrari of the Centre on Aging and Mobility at the University Hospital Zurich; she is also a visiting scientist in the Bone Metabolism Laboratory at Tufts University, Boston.

In the first year after a hip fracture, an estimated 5%–10% of patients fracture the other hip and 30% are readmitted to acute care. Half of these patients are left with permanent functional impairment, a quarter require long-term care, and 10%–25% die, she said.

Dr. Bischoff-Ferrari reported that she has no relevant financial relationships.

DENVER — Extended physiotherapy significantly reduced the rate of falls among patients with a prior hip fracture, and high-dose vitamin D significantly reduced the rate of hospital readmissions in a study of 173 patients.

A program of extended physiotherapy reduced the fall rate by 25%, compared with standard postfracture physiotherapy; high-dose vitamin D therapy reduced the hospital readmission rate by 39%, compared with a lower dose, the researchers found.

“The extended physiotherapy program, together with 2,000 IU vitamin D, has complementary benefits on post–hip fracture care,” Dr. Heike Bischoff-Ferrari said at the annual meeting of the American Society for Bone and Mineral Research.

The researchers enrolled 173 patients after their first acute hip fracture. Of these, most (79%) were women. Their mean age was 84 years, and 77% were living in the community. Half (51%) of the patients had severe vitamin D deficiency with serum 25-hydroxyvitamin D levels below 30 nmol/L; almost all (98%) had serum 25-hydroxyvitamin D levels below 75 nmol/L.

Patients were randomized to receive extended physiotherapy or standard physiotherapy. Extended physiotherapy consisted of supervised therapy for 1 hour per day during acute care, plus an unsupervised home program of exercises to perform regularly for 1 year. The standard therapy consisted of supervised therapy for 30 minutes per day during acute care.

Patients were also randomized to receive vitamin D supplementation at 2,000 IU or 800 IU vitamin D₃ per day. All patients received calcium.

Clinical assessment, which included laboratory tests and functional evaluations, took place at baseline and at 6 and 12 months' follow-up. Falls and readmissions were assessed by monthly calls to patients, patient calls to a hotline, and patient diaries.

The primary end point was the rate of falls over 12 months. The secondary end point was the rate of hospital readmission over 12 months.

In all, 86 participants were included in the high-dose vitamin D group and 87 in the lower-dose group; 87 participants were included in the extensive physiotherapy group, and 86 in the regular physiotherapy group. The groups did not differ by age, gender, BMI, cognitive function, baseline 25-hydroxyvitamin D levels, and Charleston Comorbidity Index scores.

The researchers documented 212 falls in 92 participants. Of these, 41% fell once, 26% fell twice, 19% fell three times, and 14% fell more than three times. The rate of falls per patient-year was 1.43. There were 22 new nonvertebral fractures, 9 of which were in the contralateral hip.

In terms of hospital readmissions, there were 74 readmissions among 54 participants. Of these, 72% had one readmission, 20% had two, and 8% had three. The rate of hospital readmission was 50%.

Extended physiotherapy reduced the rate of falls by 25%, compared with regular physiotherapy, a significant reduction. Similar improvements were seen in function. However, extended physiotherapy did not reduce the rate of hospital readmissions.

There was no difference in the fall rate for the two vitamin D groups, but high-dose vitamin D did reduce the rate of hospital readmission by 39%, which was significant. There was also a significant 60% reduction in fall-related injuries. “This was mainly driven by a nonsignificant reduction in repeat nonvertebral fractures by 52%,” said Dr. Bischoff-Ferrari of the Centre on Aging and Mobility at the University Hospital Zurich; she is also a visiting scientist in the Bone Metabolism Laboratory at Tufts University, Boston.

In the first year after a hip fracture, an estimated 5%–10% of patients fracture the other hip and 30% are readmitted to acute care. Half of these patients are left with permanent functional impairment, a quarter require long-term care, and 10%–25% die, she said.

Dr. Bischoff-Ferrari reported that she has no relevant financial relationships.

DENVER — Extended physiotherapy significantly reduced the rate of falls among patients with a prior hip fracture, and high-dose vitamin D significantly reduced the rate of hospital readmissions in a study of 173 patients.

A program of extended physiotherapy reduced the fall rate by 25%, compared with standard postfracture physiotherapy; high-dose vitamin D therapy reduced the hospital readmission rate by 39%, compared with a lower dose, the researchers found.

“The extended physiotherapy program, together with 2,000 IU vitamin D, has complementary benefits on post–hip fracture care,” Dr. Heike Bischoff-Ferrari said at the annual meeting of the American Society for Bone and Mineral Research.

The researchers enrolled 173 patients after their first acute hip fracture. Of these, most (79%) were women. Their mean age was 84 years, and 77% were living in the community. Half (51%) of the patients had severe vitamin D deficiency with serum 25-hydroxyvitamin D levels below 30 nmol/L; almost all (98%) had serum 25-hydroxyvitamin D levels below 75 nmol/L.

Patients were randomized to receive extended physiotherapy or standard physiotherapy. Extended physiotherapy consisted of supervised therapy for 1 hour per day during acute care, plus an unsupervised home program of exercises to perform regularly for 1 year. The standard therapy consisted of supervised therapy for 30 minutes per day during acute care.

Patients were also randomized to receive vitamin D supplementation at 2,000 IU or 800 IU vitamin D₃ per day. All patients received calcium.

Clinical assessment, which included laboratory tests and functional evaluations, took place at baseline and at 6 and 12 months' follow-up. Falls and readmissions were assessed by monthly calls to patients, patient calls to a hotline, and patient diaries.

The primary end point was the rate of falls over 12 months. The secondary end point was the rate of hospital readmission over 12 months.

In all, 86 participants were included in the high-dose vitamin D group and 87 in the lower-dose group; 87 participants were included in the extensive physiotherapy group, and 86 in the regular physiotherapy group. The groups did not differ by age, gender, BMI, cognitive function, baseline 25-hydroxyvitamin D levels, and Charleston Comorbidity Index scores.

The researchers documented 212 falls in 92 participants. Of these, 41% fell once, 26% fell twice, 19% fell three times, and 14% fell more than three times. The rate of falls per patient-year was 1.43. There were 22 new nonvertebral fractures, 9 of which were in the contralateral hip.

In terms of hospital readmissions, there were 74 readmissions among 54 participants. Of these, 72% had one readmission, 20% had two, and 8% had three. The rate of hospital readmission was 50%.

Extended physiotherapy reduced the rate of falls by 25%, compared with regular physiotherapy, a significant reduction. Similar improvements were seen in function. However, extended physiotherapy did not reduce the rate of hospital readmissions.

There was no difference in the fall rate for the two vitamin D groups, but high-dose vitamin D did reduce the rate of hospital readmission by 39%, which was significant. There was also a significant 60% reduction in fall-related injuries. “This was mainly driven by a nonsignificant reduction in repeat nonvertebral fractures by 52%,” said Dr. Bischoff-Ferrari of the Centre on Aging and Mobility at the University Hospital Zurich; she is also a visiting scientist in the Bone Metabolism Laboratory at Tufts University, Boston.

In the first year after a hip fracture, an estimated 5%–10% of patients fracture the other hip and 30% are readmitted to acute care. Half of these patients are left with permanent functional impairment, a quarter require long-term care, and 10%–25% die, she said.

Dr. Bischoff-Ferrari reported that she has no relevant financial relationships.

PHILADELPHIA — A new dressing using a lipido-colloid contact layer reduced pain during dressing changes and improved quality of life for patients with epidermolysis bullosa.

The 20 patients involved in the trial reported most of the dressing changes to be pain-free (91%). The remaining 9% of dressing changes were reported as mild to moderately painful, according to the results presented in a poster at the annual meeting of the Society for Pediatric Dermatology.

The contact layer consists of petrolatum and carboxymethylcellulose on a mesh. When exudate comes in contact with the dressing, the carboxymethylcellulose swells and retains moisture, which keeps the environment moist, said coauthor Dr. Mary Regan, who is the director of clinical affairs for Hollister Wound Care (a joint venture between Hollister Incorporated and Laboratoires URGO), which markets and sells the dressing as the Restore family in the United States. The study was funded by Laboratoires URGO, which markets and sells the dressing (UrgoCell, Urgotul) in Europe.

This open-label, single-center study involved 11 adults and 9 children with simplex or dystrophic epidermolysis bullosa. Skin lesions were managed with the lipido-colloid contact layer dressing for a maximum of 4 weeks. At dressing changes, the researchers assessed pain and quality of life.

All 20 patients completed the trial, with a total of 152 dressing changes. Dressing application was considered by the patients to be "easy" or "very easy" for most of the dressing changes (95%). Likewise, dressing removal was considered to "easy" or "very easy" for almost all of the dressing changes (98%). Dry dressing removal was recorded for 87% of dressing changes; in 13% of dressing changes saline soaking was used for removal.

Roughly half of patients (55%) reported that using the experimental dressing had improved their quality of life, due to easier dressing removal.

"Most adults and children felt less apprehensive about the procedure than they had with their usual dressing," the researchers wrote. All but one patient said that they would use the experimental dressing to manage their lesions in the future.

PHILADELPHIA — A new dressing using a lipido-colloid contact layer reduced pain during dressing changes and improved quality of life for patients with epidermolysis bullosa.

The 20 patients involved in the trial reported most of the dressing changes to be pain-free (91%). The remaining 9% of dressing changes were reported as mild to moderately painful, according to the results presented in a poster at the annual meeting of the Society for Pediatric Dermatology.

The contact layer consists of petrolatum and carboxymethylcellulose on a mesh. When exudate comes in contact with the dressing, the carboxymethylcellulose swells and retains moisture, which keeps the environment moist, said coauthor Dr. Mary Regan, who is the director of clinical affairs for Hollister Wound Care (a joint venture between Hollister Incorporated and Laboratoires URGO), which markets and sells the dressing as the Restore family in the United States. The study was funded by Laboratoires URGO, which markets and sells the dressing (UrgoCell, Urgotul) in Europe.

This open-label, single-center study involved 11 adults and 9 children with simplex or dystrophic epidermolysis bullosa. Skin lesions were managed with the lipido-colloid contact layer dressing for a maximum of 4 weeks. At dressing changes, the researchers assessed pain and quality of life.

All 20 patients completed the trial, with a total of 152 dressing changes. Dressing application was considered by the patients to be "easy" or "very easy" for most of the dressing changes (95%). Likewise, dressing removal was considered to "easy" or "very easy" for almost all of the dressing changes (98%). Dry dressing removal was recorded for 87% of dressing changes; in 13% of dressing changes saline soaking was used for removal.

Roughly half of patients (55%) reported that using the experimental dressing had improved their quality of life, due to easier dressing removal.

"Most adults and children felt less apprehensive about the procedure than they had with their usual dressing," the researchers wrote. All but one patient said that they would use the experimental dressing to manage their lesions in the future.

PHILADELPHIA — A new dressing using a lipido-colloid contact layer reduced pain during dressing changes and improved quality of life for patients with epidermolysis bullosa.

The 20 patients involved in the trial reported most of the dressing changes to be pain-free (91%). The remaining 9% of dressing changes were reported as mild to moderately painful, according to the results presented in a poster at the annual meeting of the Society for Pediatric Dermatology.

The contact layer consists of petrolatum and carboxymethylcellulose on a mesh. When exudate comes in contact with the dressing, the carboxymethylcellulose swells and retains moisture, which keeps the environment moist, said coauthor Dr. Mary Regan, who is the director of clinical affairs for Hollister Wound Care (a joint venture between Hollister Incorporated and Laboratoires URGO), which markets and sells the dressing as the Restore family in the United States. The study was funded by Laboratoires URGO, which markets and sells the dressing (UrgoCell, Urgotul) in Europe.

This open-label, single-center study involved 11 adults and 9 children with simplex or dystrophic epidermolysis bullosa. Skin lesions were managed with the lipido-colloid contact layer dressing for a maximum of 4 weeks. At dressing changes, the researchers assessed pain and quality of life.

All 20 patients completed the trial, with a total of 152 dressing changes. Dressing application was considered by the patients to be "easy" or "very easy" for most of the dressing changes (95%). Likewise, dressing removal was considered to "easy" or "very easy" for almost all of the dressing changes (98%). Dry dressing removal was recorded for 87% of dressing changes; in 13% of dressing changes saline soaking was used for removal.

Roughly half of patients (55%) reported that using the experimental dressing had improved their quality of life, due to easier dressing removal.

"Most adults and children felt less apprehensive about the procedure than they had with their usual dressing," the researchers wrote. All but one patient said that they would use the experimental dressing to manage their lesions in the future.

PHILADELPHIA — Infants with at least one typical site of nevus simplex involvement are likely to have involvement in less typical sites as well, according to a retrospective study of 28 infants.

Nevus simplex—the most common birthmark of infancy—typically affects the forehead, glabella, upper eyelids, and nape.

Among the patients in this study, approximately two-thirds had scalp involvement (69%), 64% had nose involvement, 64% had upper- or lower-lip involvement, and more than half (54%) had lumbosacral involvement, reported Dr. Anna Juern and colleagues in a poster at the annual meeting of the Society for Pediatric Dermatology.

For the study, the researchers identified 28 infants with nevus simplex who were seen at two tertiary care centers. The infants (15 girls and 13 boys) had a median age of 4.5 months.

The infants also had at least one typical site of involvement, noted Dr. Juern, a pediatric dermatology research fellow at the Medical College of Wisconsin in Milwaukee.

“It's important to recognize that widespread involvement beyond the typical sites does occur,” the researchers wrote. Nevus simplex involvement of less-typical areas may lead to confusion with port-wine stains and other vascular birthmarks.

“Using the name 'nevus simplex' to describe these [atypical] lesions will aid in the correct diagnosis of these lesions and provide reassurance to parents, due to their benign nature,” the researchers concluded.

PHILADELPHIA — Infants with at least one typical site of nevus simplex involvement are likely to have involvement in less typical sites as well, according to a retrospective study of 28 infants.

Nevus simplex—the most common birthmark of infancy—typically affects the forehead, glabella, upper eyelids, and nape.

Among the patients in this study, approximately two-thirds had scalp involvement (69%), 64% had nose involvement, 64% had upper- or lower-lip involvement, and more than half (54%) had lumbosacral involvement, reported Dr. Anna Juern and colleagues in a poster at the annual meeting of the Society for Pediatric Dermatology.

For the study, the researchers identified 28 infants with nevus simplex who were seen at two tertiary care centers. The infants (15 girls and 13 boys) had a median age of 4.5 months.

The infants also had at least one typical site of involvement, noted Dr. Juern, a pediatric dermatology research fellow at the Medical College of Wisconsin in Milwaukee.

“It's important to recognize that widespread involvement beyond the typical sites does occur,” the researchers wrote. Nevus simplex involvement of less-typical areas may lead to confusion with port-wine stains and other vascular birthmarks.

“Using the name 'nevus simplex' to describe these [atypical] lesions will aid in the correct diagnosis of these lesions and provide reassurance to parents, due to their benign nature,” the researchers concluded.

PHILADELPHIA — Infants with at least one typical site of nevus simplex involvement are likely to have involvement in less typical sites as well, according to a retrospective study of 28 infants.

Nevus simplex—the most common birthmark of infancy—typically affects the forehead, glabella, upper eyelids, and nape.

Among the patients in this study, approximately two-thirds had scalp involvement (69%), 64% had nose involvement, 64% had upper- or lower-lip involvement, and more than half (54%) had lumbosacral involvement, reported Dr. Anna Juern and colleagues in a poster at the annual meeting of the Society for Pediatric Dermatology.

For the study, the researchers identified 28 infants with nevus simplex who were seen at two tertiary care centers. The infants (15 girls and 13 boys) had a median age of 4.5 months.

The infants also had at least one typical site of involvement, noted Dr. Juern, a pediatric dermatology research fellow at the Medical College of Wisconsin in Milwaukee.

“It's important to recognize that widespread involvement beyond the typical sites does occur,” the researchers wrote. Nevus simplex involvement of less-typical areas may lead to confusion with port-wine stains and other vascular birthmarks.

“Using the name 'nevus simplex' to describe these [atypical] lesions will aid in the correct diagnosis of these lesions and provide reassurance to parents, due to their benign nature,” the researchers concluded.

PHILADELPHIA — Isotretinoin appears to derive its effectiveness from increased production of the antimicrobial protein neutrophil-gelatinase associated lipocalin in the skin, reducing sebum levels, and in turn reducing levels of Propionibacterium acnes, according to new data.

While isotretinoin is the most effective agent for patients with moderate to severe acne, the drug's teratogenicity makes alternative therapies desirable. A better understanding of the drug's mechanism of action could direct the investigation of new therapies, Kimberly Lumsden, an MD/PhD student at Pennsylvania State University, Hershey, said at the annual meeting of the Society for Pediatric Dermatology.

In vivo neutrophil-gelatinase associated lipocalin (NGAL) levels are highest 1 week after the start of isotretinoin treatment.

In addition, the study showed that in vivo sebum and P. acnes levels start to decrease during the first week of treatment with isotretinoin and continue to decrease for up to 8 weeks.

Dr. Lumsden and her colleagues recruited a patient on isotretinoin and evaluated the level of NGAL present on the skin using a tape-stripping method at weeks 1, 4, and 8.

“At 1 week we saw the greatest increase in the level of NGAL, which levels off at 4–8 weeks,” she said.

Next, they used recombinant NGAL protein and solution with P. acnes in vitro to determine if isotretinoin is antibacterial. They found a dose response. Increasing NGAL concentration led to decreased survival of P. acnes.

For the last phase, they recruited a cohort of nine patients to try to determine whether decreases in sebum and P. acnes coincide with the initial increase in NGAL levels with isotretinoin.

“We did see a decrease in sebum at 1 week and it's further decreased by 8 weeks,” she said.

However, sebum levels start to recover by about 8 weeks. As for P. acnes, there was a trend toward decreased levels at week 1 and levels continued to decrease through weeks 4 and 8.

PHILADELPHIA — Isotretinoin appears to derive its effectiveness from increased production of the antimicrobial protein neutrophil-gelatinase associated lipocalin in the skin, reducing sebum levels, and in turn reducing levels of Propionibacterium acnes, according to new data.

While isotretinoin is the most effective agent for patients with moderate to severe acne, the drug's teratogenicity makes alternative therapies desirable. A better understanding of the drug's mechanism of action could direct the investigation of new therapies, Kimberly Lumsden, an MD/PhD student at Pennsylvania State University, Hershey, said at the annual meeting of the Society for Pediatric Dermatology.

In vivo neutrophil-gelatinase associated lipocalin (NGAL) levels are highest 1 week after the start of isotretinoin treatment.

In addition, the study showed that in vivo sebum and P. acnes levels start to decrease during the first week of treatment with isotretinoin and continue to decrease for up to 8 weeks.

Dr. Lumsden and her colleagues recruited a patient on isotretinoin and evaluated the level of NGAL present on the skin using a tape-stripping method at weeks 1, 4, and 8.

“At 1 week we saw the greatest increase in the level of NGAL, which levels off at 4–8 weeks,” she said.

Next, they used recombinant NGAL protein and solution with P. acnes in vitro to determine if isotretinoin is antibacterial. They found a dose response. Increasing NGAL concentration led to decreased survival of P. acnes.

For the last phase, they recruited a cohort of nine patients to try to determine whether decreases in sebum and P. acnes coincide with the initial increase in NGAL levels with isotretinoin.

“We did see a decrease in sebum at 1 week and it's further decreased by 8 weeks,” she said.

However, sebum levels start to recover by about 8 weeks. As for P. acnes, there was a trend toward decreased levels at week 1 and levels continued to decrease through weeks 4 and 8.

PHILADELPHIA — Isotretinoin appears to derive its effectiveness from increased production of the antimicrobial protein neutrophil-gelatinase associated lipocalin in the skin, reducing sebum levels, and in turn reducing levels of Propionibacterium acnes, according to new data.

While isotretinoin is the most effective agent for patients with moderate to severe acne, the drug's teratogenicity makes alternative therapies desirable. A better understanding of the drug's mechanism of action could direct the investigation of new therapies, Kimberly Lumsden, an MD/PhD student at Pennsylvania State University, Hershey, said at the annual meeting of the Society for Pediatric Dermatology.

In vivo neutrophil-gelatinase associated lipocalin (NGAL) levels are highest 1 week after the start of isotretinoin treatment.

In addition, the study showed that in vivo sebum and P. acnes levels start to decrease during the first week of treatment with isotretinoin and continue to decrease for up to 8 weeks.

Dr. Lumsden and her colleagues recruited a patient on isotretinoin and evaluated the level of NGAL present on the skin using a tape-stripping method at weeks 1, 4, and 8.

“At 1 week we saw the greatest increase in the level of NGAL, which levels off at 4–8 weeks,” she said.

Next, they used recombinant NGAL protein and solution with P. acnes in vitro to determine if isotretinoin is antibacterial. They found a dose response. Increasing NGAL concentration led to decreased survival of P. acnes.

For the last phase, they recruited a cohort of nine patients to try to determine whether decreases in sebum and P. acnes coincide with the initial increase in NGAL levels with isotretinoin.

“We did see a decrease in sebum at 1 week and it's further decreased by 8 weeks,” she said.

However, sebum levels start to recover by about 8 weeks. As for P. acnes, there was a trend toward decreased levels at week 1 and levels continued to decrease through weeks 4 and 8.

DENVER — People on long-term glucocorticoids have a significant risk for fracture at relatively high bone mineral density T scores. As a result, physicians need to rethink their management of this population.

“In glucocorticoid osteoporosis, the fracture risk seems to take off quite dramatically somewhere around T scores of −1.5,” Dr. Philip Sambrook said during a clinical roundtable session on glucocorticoid-induced osteoporosis at the annual meeting of the American Society for Bone and Mineral Research. “Most of the guidelines around the world are now suggesting that the intervention threshold [for those on glucocorticoids] should be [a T score of] about −1.5.”

Patients on glucocorticoids typically have midline fractures of the vertebrae, where the bone just collapses in the middle of the vertebra. “This is different from the anterior wedge fracture that occurs most commonly in postmenopausal women with osteoporosis,” noted Dr. Nancy Lane, who also participated in the roundtable session. This is because there are some differences in how bones become fragile in the presence of glucocorticoids, said Dr. Lane, who is the director of the center for healthy aging at the University of California, Davis.

Dr. Sambrook, who heads the bone and joint group at the Kolling Institute of Medical Research of Royal North Shore Hospital in Sydney, presented cases that “really illustrate the type of patients that we often struggle with.”

Patient No. 1

A 66-year-old woman was recently diagnosed with polymyalgia rheumatica. She had been started on 25 mg/day prednisone and the disease activity lessened in response. Her history included chronic atopic dermatitis and hypothyroidism. She had no other medical problems. There was no family history of hip fracture. She did not smoke or drink. She had a slightly early menopause but had not used hormone therapy. She reported consuming one or two servings of dairy products daily. She also considered herself to be physically active, although she had no formal exercise program.

As part of her work-up, she had a spine x-ray, which showed a vertebral deformity (compression). BMD measurements showed modest osteopenia (T scores of −1.5 at the spine and −1.6 at the hip). She had normal levels of calcium and parathyroid hormone (PTH). Her vitamin D level was equivocal, however. Her thyroid function was normal.

This patient had modest osteopenia at the time of her diagnosis. Once she was started on glucocorticoids, her T scores could have fallen rapidly and then stabilized over time, without treatment for bone loss, said Dr. Sambrook. “As she becomes established on glucocorticoids, she will perhaps not lose that much bone,” but she's at risk of fracture.

So, when clinical trial data are interpreted, it's important to keep two clinical scenarios in mind: prevention (when initial rapid loss of bone is to be avoided) and treatment (when the patient is on chronic glucocorticoids and may not be losing a lot of bone but is still at risk for fracture).

“Most of us would believe that vitamin D [plus] calcium is an adjunctive therapy,” said Dr. Sambrook. The data appear to back that up. In a 1996 trial, patients with glucocorticoid osteoporosis were randomized to 50,000 U/week of vitamin D plus 1,000 mg/day of calcium, or placebo. Both groups lost bone at the spine quite rapidly, although there was a trend for patients on vitamin D and calcium to do slightly better (J. Rheumatol. 1996;23:995-1000).

In another study, researchers demonstrated that daily alendronate increases bone density in patients who receive glucocorticoid therapy, compared with those on placebo (N. Engl. J. Med. 1998;339:292-9). Similar results have been demonstrated with etidronate, risedronate, and zoledronic acid.

Dr. Sambrook recommended that the patient receive calcium and vitamin D supplementation. Also, “we would primarily give her bisphosphonates until prednisone is discontinued” and possibly beyond, depending on her overall fracture risk after prednisone treatment.

Patient No. 2

A 24-year-old woman has had systemic lupus erythematosus for 3 years, and the disease has become severe over that time. Her SLE complications have included encephalitis, vasculitis, renal involvement, and deep vein thrombosis. She had no family history of osteoporosis. She did not consume much dietary calcium, although she claimed to get adequate sun exposure. She had been on an oral contraceptive since the age of 17. Her appetite and weight were average and stable.

At the time of her presentation, she had been on prednisone for 6 months, with dosages averaging 25-50 mg daily. However, the recent onset of renal complications required increasing the dose to 75 mg daily. She was also taking an antimalaria drug. Her vitamin D level was equivocal and needed to be addressed. She had normal calcium and PTH levels and normal thyroid function. However, her spine T score was −1.4 and her hip T score was −1.0.

The concern to Dr. Sambrook was the effect of bisphosphonates on fetal development. Although the patient was not pregnant at the start of therapy, she might have become so intentionally or unintentionally. Bisphosphonates are classified as pregnancy category C drugs by the U.S. Food and Drug Administration, meaning that they are contraindicated in pregnancy.

One approach to managing this patient is to simply watch her and measure BMD in 12 months. Another is to use a bisphosphonate in conjunction with vitamin D and calcium supplementation. Risedronate might be the better choice, given its quicker onset and offset of action, he said.

“As long as she stayed on prednisone, I might not be as aggressive as with postmenopausal women,” Dr. Sambrook noted. If the prednisone dose was decreased, he said that he might consider stopping bisphosphonate treatment.

Dr. Lane and Dr. Sambrook both reported financial relationships with several pharmaceutical companies.

Whole-body dual-energy x-ray absorptiometry can provide information on total and regional BMD (left) and body composition (fat and muscle mass).

Source ©ELSEVIER

DENVER — People on long-term glucocorticoids have a significant risk for fracture at relatively high bone mineral density T scores. As a result, physicians need to rethink their management of this population.

“In glucocorticoid osteoporosis, the fracture risk seems to take off quite dramatically somewhere around T scores of −1.5,” Dr. Philip Sambrook said during a clinical roundtable session on glucocorticoid-induced osteoporosis at the annual meeting of the American Society for Bone and Mineral Research. “Most of the guidelines around the world are now suggesting that the intervention threshold [for those on glucocorticoids] should be [a T score of] about −1.5.”

Patients on glucocorticoids typically have midline fractures of the vertebrae, where the bone just collapses in the middle of the vertebra. “This is different from the anterior wedge fracture that occurs most commonly in postmenopausal women with osteoporosis,” noted Dr. Nancy Lane, who also participated in the roundtable session. This is because there are some differences in how bones become fragile in the presence of glucocorticoids, said Dr. Lane, who is the director of the center for healthy aging at the University of California, Davis.

Dr. Sambrook, who heads the bone and joint group at the Kolling Institute of Medical Research of Royal North Shore Hospital in Sydney, presented cases that “really illustrate the type of patients that we often struggle with.”

Patient No. 1

A 66-year-old woman was recently diagnosed with polymyalgia rheumatica. She had been started on 25 mg/day prednisone and the disease activity lessened in response. Her history included chronic atopic dermatitis and hypothyroidism. She had no other medical problems. There was no family history of hip fracture. She did not smoke or drink. She had a slightly early menopause but had not used hormone therapy. She reported consuming one or two servings of dairy products daily. She also considered herself to be physically active, although she had no formal exercise program.

As part of her work-up, she had a spine x-ray, which showed a vertebral deformity (compression). BMD measurements showed modest osteopenia (T scores of −1.5 at the spine and −1.6 at the hip). She had normal levels of calcium and parathyroid hormone (PTH). Her vitamin D level was equivocal, however. Her thyroid function was normal.

This patient had modest osteopenia at the time of her diagnosis. Once she was started on glucocorticoids, her T scores could have fallen rapidly and then stabilized over time, without treatment for bone loss, said Dr. Sambrook. “As she becomes established on glucocorticoids, she will perhaps not lose that much bone,” but she's at risk of fracture.

So, when clinical trial data are interpreted, it's important to keep two clinical scenarios in mind: prevention (when initial rapid loss of bone is to be avoided) and treatment (when the patient is on chronic glucocorticoids and may not be losing a lot of bone but is still at risk for fracture).

“Most of us would believe that vitamin D [plus] calcium is an adjunctive therapy,” said Dr. Sambrook. The data appear to back that up. In a 1996 trial, patients with glucocorticoid osteoporosis were randomized to 50,000 U/week of vitamin D plus 1,000 mg/day of calcium, or placebo. Both groups lost bone at the spine quite rapidly, although there was a trend for patients on vitamin D and calcium to do slightly better (J. Rheumatol. 1996;23:995-1000).

In another study, researchers demonstrated that daily alendronate increases bone density in patients who receive glucocorticoid therapy, compared with those on placebo (N. Engl. J. Med. 1998;339:292-9). Similar results have been demonstrated with etidronate, risedronate, and zoledronic acid.

Dr. Sambrook recommended that the patient receive calcium and vitamin D supplementation. Also, “we would primarily give her bisphosphonates until prednisone is discontinued” and possibly beyond, depending on her overall fracture risk after prednisone treatment.

Patient No. 2

A 24-year-old woman has had systemic lupus erythematosus for 3 years, and the disease has become severe over that time. Her SLE complications have included encephalitis, vasculitis, renal involvement, and deep vein thrombosis. She had no family history of osteoporosis. She did not consume much dietary calcium, although she claimed to get adequate sun exposure. She had been on an oral contraceptive since the age of 17. Her appetite and weight were average and stable.

At the time of her presentation, she had been on prednisone for 6 months, with dosages averaging 25-50 mg daily. However, the recent onset of renal complications required increasing the dose to 75 mg daily. She was also taking an antimalaria drug. Her vitamin D level was equivocal and needed to be addressed. She had normal calcium and PTH levels and normal thyroid function. However, her spine T score was −1.4 and her hip T score was −1.0.

The concern to Dr. Sambrook was the effect of bisphosphonates on fetal development. Although the patient was not pregnant at the start of therapy, she might have become so intentionally or unintentionally. Bisphosphonates are classified as pregnancy category C drugs by the U.S. Food and Drug Administration, meaning that they are contraindicated in pregnancy.

One approach to managing this patient is to simply watch her and measure BMD in 12 months. Another is to use a bisphosphonate in conjunction with vitamin D and calcium supplementation. Risedronate might be the better choice, given its quicker onset and offset of action, he said.

“As long as she stayed on prednisone, I might not be as aggressive as with postmenopausal women,” Dr. Sambrook noted. If the prednisone dose was decreased, he said that he might consider stopping bisphosphonate treatment.

Dr. Lane and Dr. Sambrook both reported financial relationships with several pharmaceutical companies.

Whole-body dual-energy x-ray absorptiometry can provide information on total and regional BMD (left) and body composition (fat and muscle mass).

Source ©ELSEVIER

DENVER — People on long-term glucocorticoids have a significant risk for fracture at relatively high bone mineral density T scores. As a result, physicians need to rethink their management of this population.

“In glucocorticoid osteoporosis, the fracture risk seems to take off quite dramatically somewhere around T scores of −1.5,” Dr. Philip Sambrook said during a clinical roundtable session on glucocorticoid-induced osteoporosis at the annual meeting of the American Society for Bone and Mineral Research. “Most of the guidelines around the world are now suggesting that the intervention threshold [for those on glucocorticoids] should be [a T score of] about −1.5.”

Patients on glucocorticoids typically have midline fractures of the vertebrae, where the bone just collapses in the middle of the vertebra. “This is different from the anterior wedge fracture that occurs most commonly in postmenopausal women with osteoporosis,” noted Dr. Nancy Lane, who also participated in the roundtable session. This is because there are some differences in how bones become fragile in the presence of glucocorticoids, said Dr. Lane, who is the director of the center for healthy aging at the University of California, Davis.

Dr. Sambrook, who heads the bone and joint group at the Kolling Institute of Medical Research of Royal North Shore Hospital in Sydney, presented cases that “really illustrate the type of patients that we often struggle with.”

Patient No. 1

A 66-year-old woman was recently diagnosed with polymyalgia rheumatica. She had been started on 25 mg/day prednisone and the disease activity lessened in response. Her history included chronic atopic dermatitis and hypothyroidism. She had no other medical problems. There was no family history of hip fracture. She did not smoke or drink. She had a slightly early menopause but had not used hormone therapy. She reported consuming one or two servings of dairy products daily. She also considered herself to be physically active, although she had no formal exercise program.

As part of her work-up, she had a spine x-ray, which showed a vertebral deformity (compression). BMD measurements showed modest osteopenia (T scores of −1.5 at the spine and −1.6 at the hip). She had normal levels of calcium and parathyroid hormone (PTH). Her vitamin D level was equivocal, however. Her thyroid function was normal.

This patient had modest osteopenia at the time of her diagnosis. Once she was started on glucocorticoids, her T scores could have fallen rapidly and then stabilized over time, without treatment for bone loss, said Dr. Sambrook. “As she becomes established on glucocorticoids, she will perhaps not lose that much bone,” but she's at risk of fracture.

So, when clinical trial data are interpreted, it's important to keep two clinical scenarios in mind: prevention (when initial rapid loss of bone is to be avoided) and treatment (when the patient is on chronic glucocorticoids and may not be losing a lot of bone but is still at risk for fracture).

“Most of us would believe that vitamin D [plus] calcium is an adjunctive therapy,” said Dr. Sambrook. The data appear to back that up. In a 1996 trial, patients with glucocorticoid osteoporosis were randomized to 50,000 U/week of vitamin D plus 1,000 mg/day of calcium, or placebo. Both groups lost bone at the spine quite rapidly, although there was a trend for patients on vitamin D and calcium to do slightly better (J. Rheumatol. 1996;23:995-1000).

In another study, researchers demonstrated that daily alendronate increases bone density in patients who receive glucocorticoid therapy, compared with those on placebo (N. Engl. J. Med. 1998;339:292-9). Similar results have been demonstrated with etidronate, risedronate, and zoledronic acid.

Dr. Sambrook recommended that the patient receive calcium and vitamin D supplementation. Also, “we would primarily give her bisphosphonates until prednisone is discontinued” and possibly beyond, depending on her overall fracture risk after prednisone treatment.

Patient No. 2

A 24-year-old woman has had systemic lupus erythematosus for 3 years, and the disease has become severe over that time. Her SLE complications have included encephalitis, vasculitis, renal involvement, and deep vein thrombosis. She had no family history of osteoporosis. She did not consume much dietary calcium, although she claimed to get adequate sun exposure. She had been on an oral contraceptive since the age of 17. Her appetite and weight were average and stable.

At the time of her presentation, she had been on prednisone for 6 months, with dosages averaging 25-50 mg daily. However, the recent onset of renal complications required increasing the dose to 75 mg daily. She was also taking an antimalaria drug. Her vitamin D level was equivocal and needed to be addressed. She had normal calcium and PTH levels and normal thyroid function. However, her spine T score was −1.4 and her hip T score was −1.0.

The concern to Dr. Sambrook was the effect of bisphosphonates on fetal development. Although the patient was not pregnant at the start of therapy, she might have become so intentionally or unintentionally. Bisphosphonates are classified as pregnancy category C drugs by the U.S. Food and Drug Administration, meaning that they are contraindicated in pregnancy.

One approach to managing this patient is to simply watch her and measure BMD in 12 months. Another is to use a bisphosphonate in conjunction with vitamin D and calcium supplementation. Risedronate might be the better choice, given its quicker onset and offset of action, he said.

“As long as she stayed on prednisone, I might not be as aggressive as with postmenopausal women,” Dr. Sambrook noted. If the prednisone dose was decreased, he said that he might consider stopping bisphosphonate treatment.

Dr. Lane and Dr. Sambrook both reported financial relationships with several pharmaceutical companies.

Whole-body dual-energy x-ray absorptiometry can provide information on total and regional BMD (left) and body composition (fat and muscle mass).

Source ©ELSEVIER