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Rapid Responses: Rapid Responses published:
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An incomplete article
- Anthony N Glaser (15 December 2006)
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Osteoporosis and its management
- Alan W Fowler (17 December 2006)
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Osteoporosis : what of the Asian, African and South American patient?
- Suranjith L Seneviratne, Padmalal Gurugama, Registrar, Peradeniya Teaching Hospital, Sri Lanka and Devaka J Fernando, Consultant Endocrinologist, KingsMill Hospital, Nottinghamshire, UK (17 December 2006)
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Multiple myeloma mimics osteoporosis – biochemical markers are useful
- Amit Patel (21 December 2006)
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Incorrect label on figure 2
- Susan M Ott (10 January 2007)
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Osteoporosis education is central to treatment
- Sarah J Abrahamson (20 January 2007)
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What about renal failure?
- Giles E Aldworth (21 January 2007)
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Use of percutaneous vertebroplasty and kyphoplasty for the management of osteoporotic vertebral compression fractures
- Dino Samartzis, Francis H. Shen (27 January 2007)
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Anthony N Glaser, Private practice of family medicine Summerville, SC 29483, USA
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Unfortunately, although it is good as far as it goes, this article fails to even mention three of the "hot topics" in this area, which include questions that many of my patients are concerned about: 1 - the risk of osteonecrosis of the jaw in patients taking bisphosphonates (yes, I see it in some of my primary care patients) 2 - how long to continue a bisphosphonate for 3 - the worrying reports suggesting that patients who do sustain fractures while on or after having been on bisphosphonates have poorer fracture healing rates . . . and what is the NNT for bisphosphonates? (Not very good, I believe) Competing interests: None declared |
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Alan W Fowler, Retired orthopaedic surgeon Home CF31 1QJ
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Alan W. Fowler FRCS High View, Litchard Rise, BRIDGEND,CF31 1QJ Tel. 01656 652671 email alan@awfowler.fsnet.co.uk 15. 12.06 Osteoporosis and its management Editor – In their clinical review of osteoporosis1 the authors include calcium intake as one of the many factors influencing bone mass but, surprisingly, they do not mention the role of sodium in calcium balance and the fact that there is a linear relationship between urinary excretion of calcium and sodium. Thus hypercalcaemia can be treated by sodium and frusemide. Proof of the long- term benefit of sodium restriction in osteoporosis is difficult to achieve because of the difficulty in maintaining a physiological level of sodium intake over many years, but we do know that dietary salt increases biological markers of bone resorption.2 There are therefore powerful a priori reasons for advocating sodium restriction as part of our package for the prevention and treatment of osteoporosis. 1. Pool KES, Compston JE. Osteoporosis and its management. BMJ 2006; 333:1251-6. 2. McFarland BE, Goulding A, Campbell AJ. Dietary salt affects biochemical markers of resorption and formation of bone in elderly women. BMJ 1989;299:834- 5. Alan W Fowler Competing interests: None declared |
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Suranjith L Seneviratne, Consultant Clinical Immunologist Manchester Royal Infirmary, Manchester, UK, Padmalal Gurugama, Registrar, Peradeniya Teaching Hospital, Sri Lanka and Devaka J Fernando, Consultant Endocrinologist, KingsMill Hospital, Nottinghamshire, UK
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Poole and Compston clearly and concisely highlight important points on osteoporosis to be considered by the practising clinician1. The effects of age and sex of the individual and a range of other factors on risk, diagnosis, management and prognosis of osteoporosis were discussed. However, no mention was made on how a persons ethnic origin factors into this equation. Physicians managing patients from ethnic minorities in developed western countries (nearly 10 - 20% in some UK cities like Manchester) or developing countries in Asia, Africa and South America would wish to know if and how recommendations on diagnosis, management and prognosis apply to their individual patients. For example, in relation to waist circumference which forms a crucial diagnostic criterion of the metabolic syndrome, the optimal screening cut-off points may be population specific and even within a given population differ according to ethnic grouping2. Similar considerations are seen with cardiovascular disease3. The relevance of findings on osteoporosis in Europid subjects need to be tested in other patient groups. It would be a folly to be complacent and assume direct transferability of findings among different ethnic groups. All too often one witnesses the direct application of findings and recommendations on Europid populations being applied directly to other ethnic groups with little consideration been given to whether they have the same benefit and more importantly if certain interventions may actually cause harm4. In all probability little information on osteoporosis is available from different ethnic settings. A quick Pubmed search using the term ‘osteoporosis and the names of different countries’ found over 1000 hits for the UK or the USA, under 10 hits each for Sri Lanka, Pakistan, Nepal, Kenya or Peru and under 60 hits each for India, Thailand, South Africa, Brazil or Argentina. Of the many reports from the UK and the USA, only a handful included patients from non-Europid backgrounds5. Even if such information is generally sketchy it would not be wise to completely ignore this aspect. Actually the anomaly should be highlighted prominently in any review on the subject. Clinicians and researchers should be urged to study this aspect to ensure availability of more information at least in the future. An important addition to the ‘tips for the non-specialist’ section of the review would be to audit the use of osteoporosis related non-drug and drug interventions in different ethnic cohorts. This may allow us to assess the degree of benefit and possible ill effects according to ethnic groupings and move us further ahead in making context specific recommendations. 1. Poole KES, Compston JE. Osteoporosis and its management. BMJ 2006; 333; 1251 – 56. 2. Molarius A, Seidell JC, Sans S, Tuomilheto J, Kuulasmaa K Varying sensitivity of waist action levels to identify subjects with overweight or obesity in 19 populations of the WHO MONICA project J Clin Epidemiol 1999;52:1213-24. 3. McKenzie DB, Wilcox RG. Heart failure: treatment and ethnic origin. Lancet 2003; 362: 919 4. Matthews HW. Racial, ethnic and gender differences in response to medicines. Drug Metabol Drug Interact 1995; 12: 77 - 91 5. Mehta G, Taylor P, Petley G, Dennison E, Cooper C, Walker-Bone K. Bone mineral status in immigrant Indo-Asian women. Q J Med 2004; 97: 95 – 99. Suranjith L Seneviratne: Consultant Clinical Immunologist, Manchester Royal Infirmary, Manchester, UK Padmalal Gurugama: Registrar in Internal Medicine, Peradeniya Teaching Hospital, Sri Lanka Devaka J Fernando: Consultant Endocrinologist, KingsMill Hospital, Nottinghamshire, UK Competing interests: None declared |
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Amit Patel, Academic Clincal Fellow & Specialist Registrar in Haematology The Hammersmith Hospitals NHS Trust, Charing Cross Hospital, London, W6 8RF, UK
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The overview by Poole[1] suggests a bone chemistry profile, serum immunoglobulins, paraprotein and urinary Bence-Jones protein estimation to exclude multiple myeloma as a secondary cause of osteoporosis. One should remember that of the 80% of skeletal surveys that demonstrate an abnormality in myeloma, 5-10% only show osteoporosis, without lytic lesions or fractures. Around 80% of patients have a serum paraprotein, with around 20% having only urinary Bence-Jones protein. If neither is detectable, free serum light chain estimation maybe warranted to diagnose light chain disease, amyloid and the 1% of patients that have non- secretory multiple myeloma. In the latter, light chains may also provide a treatment response parameter in most patients. Both intravenous and oral clodronate have been demonstrated to reduce bone loss and treat the hypercalcaemia that results from myeloma in large prospective randomised controlled trials.[2] Like most bisphosphonates, it is well tolerated in most. However, the risk of osteonecrosis of the jaw[3] in addition to oesophageal and oral ulceration should be considered when commencing long-term treatment with any bisphosphonate, particularly with intravenous preparations. Specific biochemical markers of bone turnover, such as serum osteocalcin, have been shown to predict the risk of osteoporosis and help monitor the effects of drugs used to treat it, and are more closely linked to fracture risk reduction than changes in bone mineral density (BMD).[4] Early treatment effect can be monitored, as BMD changes may take up to two years to become evident. Those predicted to be non-responders to bisphosphonate therapy at three months using urinary markers, such as type I collagen N-telopeptide,[5] can stop or change therapy, preventing the potentially serious side-effects discussed. [1] Poole KES, Compston JE. Osteoporosis and its management. BMJ 2006;333:1251-56. [2] McCloskey EV, MacLennan IC, Drayson MT, Chapman C, Dunn J, Kanis JA. A randomized trial of the effect of clodronate on skeletal morbidity in multiple myeloma. MRC Working Party on Leukaemia in Adults. Br J Haematol 1998;100:317-25. [3] Treister N, Woo SB. Bisphosphonate-Associated Osteonecrosis of the Jaw. N Engl J Med 2006;355:2348. [4] Sarkar S, Reginster JY, Crans GG, Diez-Perez A, Pinette KV, Delmas PD. Relationship between changes in biochemical markers of bone turnover and BMD to predict vertebral fracture risk. J Bone Miner Res 2004;19:394-401. [5] Kim SW, Park DJ, Park KS, Kim SY, Cho BY, Lee HK, Shin CS. Early changes in biochemical markers of bone turnover predict bone mineral density response to antiresorptive therapy in Korean postmenopausal women with osteoporosis. Endocr J 2005;52:667-74. Competing interests: None declared |
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Susan M Ott, physician University of Washington
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On figure 2, the label has mixed the hip fractures (which occur later in life) with the vertebral fractures. Competing interests: None declared |
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Sarah J Abrahamson, Rehabilitation Physician Queen Elizabeth Centre, 102 Ascot St, Ballarat, Victoria 3350, Australia
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In this clinical review there is an alarming discrepancy between the level of evidence used to describe the aspects of medical management and patient education, and subsequent compliance. The issues of education and compliance, which are closely linked, are only alluded to in two tables, but not discussed in the text at all. The statement is made that compliance is poor, but can be improved with education. Only one reference focused on the issue of compliance. I suggest that the reason why compliance is poor is that osteoporosis treatment is not lifesaving for the vast majority of patients, but reduces the risk of a problem which is painful and inconvenient, while causing minor immediate inconvenience in taking the medications, and with some risk of side-effects. Consequently, for osteoporosis treatment, more than almost any other category of medication, the key focus should be education, and full consent to treatment. This may mean that some patients refuse treatment rather than start it and later add to the low compliance rates: this is their right. We have found (1) that the compliance rate for osteoporosis medications is close to one hundred percent when the need for the medications has been thoroughly discussed with the patient. However, noone should suggest that all patients should be on medications, and anyone attempting to start medications on all of their osteoporotic patients is bound for some disappointment. Reference 1.Abrahamson SJ and Khan F. Brief osteoporosis education in an inpatient rehabilitation setting improves knowledge of osteoporosis in elderly patients with low trauma fracture. Int Jour Rehab Res 2006;29:61-64. Competing interests: None declared |
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Giles E Aldworth, Staff Grade in Orthogeriatrics Ulster Hospital Dundonald BT16 1RH
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I would be grateful to hear your advice on how to manage osteoporotic patients with renal failure, given that manufacturers advise against alendronate, risedronate and strontium at similar levels of glomerular filtration rate.
Competing interests: None declared |
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Dino Samartzis, Medical Scientist & Clinical Epidemiologist Radiation Effects Research Foundation, Hiroshima, Japan, 732-0815, Francis H. Shen
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We wish to commend Poole and Compston (1) regarding their succinct and informative clinical review of the management of osteoporosis. It is well known that osteoporosis is a global concern associated with a variety of health care and socioeconomic burdens. The management options for addressing osteoporosis are numerous, and advances in biotechnology and various drug therapies have been developed in the attempt to address many of the pitfalls associated with this disease. The authors note in their summary statement that “Vertebral fractures in particular remain under- recognised and under-treated and are associated with poor health outcomes.” Of further interest, the authors also stress that compliance of the osteoporotic patient to treatment régimes and/or lifestyle changes is unfortunately low. However, what the authors did not address in light of such concerns – and which was perhaps beyond the scope of their article – was the role of percutaneous vertebroplasty or kyphoplasty in the management of osteoporotic vertebral compression fractures (VCFs). It is commonly known that VCFs represent the most common complication related to osteoporosis, with approximately one-third of such fractures being associated with chronic pain. (2) Furthermore, VCFs may be associated with and increased mortality rate and affect the normal sagittal balance of the spinal column, often leading to back pain, impaired spinal mobility, spinal deformity, increased incidence of sustaining additional spinal fractures, decreased functional activity, and overall deleterious affects upon the quality of life. (3, 4) Also, until VCFs heal, they may be mobile and settle in a malaligned position. (5) Due to the numerous complications associated with open and invasive procedures to treat VCFs (often in older patients already possessing several co- morbidities), operative management has been avoided unless gross spinal instability or neurologic compromise was evident; thereby, traditionally, conservative medical management coupled with initial bed rest and bracing has been the norm for such spinal fractures. However, such immobilization can lead to further bone loss and individuals with concomitant co- morbidities (i.e. pulmonary disease, rheumatoid arthritis) may not tolerate bracing well. More recently, however, percutaneous vertebroplasty and kyphoplasty have been developed to help address some of the aforementioned concerns with osteoporotic VCFs. Both are minimally invasive procedures that have been reported to offer immediate pain relief in the management of VCFs, which translates into a quicker return to daily activities and increased function. (6, 7) Such procedures are characterized by their percutaneous delivery of bone cement or other bioactive substrates directly into the fractured vertebral body. In addition, kyphoplasty further employs the use of a percutaneous inflatable balloon bone tamp, which may facilitate to some extent the reconstitution of vertebral body height and sagittal spinal alignment. (7-10) Conversely, as with any procedure, various indications and contraindications exist with such treatment modalities, stressing the importance of proper patient selection. Awareness of such additional management options for patients suffering from progressive and painful osteoporotic VCFs is imperative. Understanding and implementing in select patients the appropriate use of such minimally invasive techniques avoids the downfalls associated with conservative or traditional management options of osteoporotic VCFs. Dino Samartzis, DSc, PhD (C ), MSc Medical Scientist and Clinical Epidemiologist Harvard University, Cambridge, Massachusetts, USA Radiation Effects Research Foundation, Hiroshima, Japan Francis H. Shen, MD Orthopaedic Spine Surgeon University of Virginia, Charlottesville, Virginia, USA References 1. Poole KE, Compston JE. Osteoporosis and its management. BMJ 2006;333(7581):1251-6. 2. Riggs BL, Melton LJ, 3rd. The worldwide problem of osteoporosis: insights afforded by epidemiology. Bone 1995;17(5 Suppl):505S-511S. 3. Garfin SR, Buckley RA, Ledlie J. Balloon kyphoplasty for symptomatic vertebral body compression fractures results in rapid, significant, and sustained improvements in back pain, function, and quality of life for elderly patients. Spine 2006;31(19):2213-20. 4. Kado DM, Browner WS, Palermo L, Nevitt MC, Genant HK, Cummings SR. Vertebral fractures and mortality in older women: a prospective study. Study of Osteoporotic Fractures Research Group. Arch Intern Med 1999;159(11):1215-20. 5. McKiernan F, Jensen R, Faciszewski T. The dynamic mobility of vertebral compression fractures. J Bone Miner Res 2003;18(1):24-9. 6. Jensen ME, Evans AJ, Mathis JM, Kallmes DF, Cloft HJ, Dion JE. Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. AJNR Am J Neuroradiol 1997;18(10):1897-904. 7. Taylor RS, Taylor RJ, Fritzell P. Balloon kyphoplasty and vertebroplasty for vertebral compression fractures: a comparative systematic review of efficacy and safety. Spine 2006;31(23):2747-55. 8. Grafe IA, Da Fonseca K, Hillmeier J, Meeder PJ, Libicher M, Noldge G, et al. Reduction of pain and fracture incidence after kyphoplasty: 1-year outcomes of a prospective controlled trial of patients with primary osteoporosis. Osteoporos Int 2005;16(12):2005-12. 9. Grohs JG, Matzner M, Trieb K, Krepler P. Minimal invasive stabilization of osteoporotic vertebral fractures: a prospective nonrandomized comparison of vertebroplasty and balloon kyphoplasty. J Spinal Disord Tech 2005;18(3):238-42. 10. Shindle MK, Gardner MJ, Koob J, Bukata S, Cabin JA, Lane JM. Vertebral height restoration in osteoporotic compression fractures: kyphoplasty balloon tamp is superior to postural correction alone. Osteoporos Int 2006;17(12):1815-9. Competing interests: None declared |
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