Sociedad Española de Investigacion Ósea y Metabolismo Mineral

Revista de Osteoporosis y Metabolismo Mineral

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Author: Romm

Osteoporosis. Definition. Epidemiology

Osteoporosis is a global health problem whose importance is going to increase with the aging of the population. It is defined as a systemic disorder of the skeleton characterised by low bone mass and deterioration of the microarchitecture of the bone tissue, with the consequent increase in bone fragility and the greater susceptibility to fractures1. Bone resistance reflects essentially the combination of bone density and bone quality. In turn, the concept of bone quality seeks to integrate all those factors apart from bone mass which determine bone fragility, including the microarchitecture, the degree of turnover, the accumulation of lesions or microfractures, or the degree of mineralisation1,2.
It is a process which is preventable and treatable, but which lacks warning signs prior to the appearance of fractures, leading to the fact of few patients being diagnosed at early stages and treated effectively. Therefore, in some studies it has been confirmed that 95% of patients who presented with a fracture did not have an earlier diagnosis of osteoporosis3.
In 1994 the World Health Organisation (WHO) established some definitions based on measurements of bone mass in the lumbar spine, hip or forearm of white postmenopausal women4. Thus, normal bone mass is considered to be having a bone mineral density (BMD) value higher than -1 standard deviation (SD) in relation to the average for young adults (T-score >-1); osteopenia, having BMD values between -1 and -2.5 SD (T-score between -1 and -2.5); osteoporosis, having BMD values lower than -2.5 SD (T-score lower than -2.5), and osteoporosis is established when, along with the above conditions, are associated one or more fragility fractures (Table 1). It is also possible to consider the Z-score in groups of patients such as children and young adults, which expresses the bone mass in comparison with that expected in those of equal age and sex5.

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Clinical Practice Guidelines for Posmenopausal, Esteroid and Male Osteoporosis

Introduction

When the last version of the “Clinical Practice Guidelines for Posmenopausal, Esteroid and Male Osteoporosis”, Society of Bone and Mineral Metabolism Research1 was produced it was agreed that it should be revised at least every 5-6 years, by editing a new version of the same document. At an intermediate point –at around 2-3 years– an update should have been produced, to include issues which could not wait for the editing of the new version, especially taking into account the fact that even as the second version was written the introduction to market of the new drugs was already being foreseen. The following document includes this update. It should be stressed that this should not be treated as an entire revision of the guides, rather only of some aspects –fundamentally therapeutic issues– considered most urgent.
Given that this should not be treated as a complete revision of the guides, rather only its update, we have considered it proper to take into account solely information relevant from the practical point of view; specifically, information related to the efficacy of the drugs in reducing the incidence of fractures. We have not assessed data related to substituted variables, such as Bone Mineral Density (BMD) or markers for bone turnover. However, we have included comparative studies or non-inferiority studies regularly carried out with BMD as a variable of efficacy, given that they definitely constitute an indirect way of establishing the usefulness of a particular drug –or in a particular way of administering them– for fractures.

Methodology

A systematic search of the bibliography in PubMed was carried out, with two different approaches: a) a search under “Theraputics”, of the “Clinical Enquiries” section, using the names of the various drugs; b) a search starting with the MeSH terms, using the names of the various drugs, plus the terms “fracture” or “osteoporosis”. The names of the drugs used in the searches were the following: etidronate, alendronate, risedronate, ibandronate, zoledronate, strontium ranelate, oestrogens, hormone replacement therapy, raloxifene, tibolone, calcitonin, PTH, parathormone, PTH 1-34, teriparatide, PTH 1-84, fluoride. The period of the bibliographic search started in January 2006, the point at which the systematic search for the second version of the guides ceased, and ended in December 2008. In addition to the works found in the systematic search over the aforementioned period, we also considered for this update information based on personal knowledge gained through regular handling of the bibliography related to this subject, and data presented at conferences; this information was included even though it was collected after the systematic search had been completed.
In order to assess efficacy in relation to fractures we analysed only works designed as clinical trials or meta-analyses, rejecting observational studies.
A first draft was written by the co-ordinator of guides (JGM), which was distributed among all the members of the Committee of Experts of the SEIOMM charged with producing the second version. They proposed changes to the document, according to which a second draft was produced, which again was sent to the members of the Committee. Finally, with the comments on this second draft the final, definitive version was produced, which was approved by the Committee. The document was submitted for the consideration of the scientific societies interested in osteoporosis.

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Socioeconomic impact of osteoporosis

Osteoporosis (OP) is included in the group of diseases which constitute the greatest health problems in the world, both for its ubiquity and for its socioeconomic consequences. In the United States of America it has been calculated that around 10 million people have OP and that nearly 34 million are at risk of suffering a fracture due to their having low bone mass1. In Spain, it is estimated that 3 million people suffer from OP and that this would mean an incidence of hip fracture of approximately 6.94 ± 0.44 per 1,000 inhabitants per year2. However, it is difficult to know exactly the global reach of OP since only data on femoral fractures is known with any exactitude, because it is the only one which always requires hospitalisation. In fact it would be possible to divide the consequences of OP into three well differentiated types of fracture: vertebral fracture (VF), femoral fracture (FF) and non-vertebral, non-hip fracture (NVF). VF has the inconvenience that it is only symptomatic in 30% of cases, and despite a third of vertebral fractures requiring specific medical attention, the rest are underestimated and remain diagnosed as back pain or arthritic lumbago3. FFs are the only truly quantifiable of these fractures, since they always require hospitalisation, at least in countries described as developed, and their costs can be assessed with greater accuracy. NVFs, which would include fractures of the forearm, humerus, clavicle, ribs, and ankle, are also very difficult to quantify, since although some cases require surgical intervention, the majority are attended to in outpatients or casualty departments of hospitals without the patient being admitted.

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Codification of hip fractures

To the Director:

The fracture of the proximal extremity of the femur, known also as a hip fracture, constitutes the most serious clinical complication of osteoporosis1, leading to an increase both in the morbidity and the mortality of the patients who suffer it2-4. Practically all hip fractures are admitted to hospital, where they are mostly dealt with by surgical intervention5. For many years, in all the hospitals in our country, a system of coding for diseases is applied, based on the international classification of diseases, or ICD • 9 •6. These codes are applied both in the clinical history and in the databases of hospital archives
It might be thought that the collection of epidemiological data on hip fractures is simple, since by practically all cases being admitted to hospitals, they would be easily identifiable7. However, we believe that in reality this is not the case, and that it is possible that we are losing information on the true prevalence both of fractures of the hip and on osteoporosis and vertebral fractures, because the current coding allows many options.

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Evolution of bone mineral density after a 15 year intervention based on progressive force training

Dear Editor,

Osteoporosis is the most common bone disorder in humans, affecting older people at a very high rate. It consists of an imbalance in bone formation-resorption which principally affects its strength and resistance, resulting in an increase in risk of fractures1. This situation is associated with high levels of morbidity and mortality2. One of the many causes which affect this relationship is the history of the mechanical load taken by the bone3, and, according to the law proposed by Dr Wolff, the stress or mechanical load applied to the bone through the tendon and generated by the muscle. Pharmacological intervention for osteoporosis includes drugs of the biphosphonate family, the selective oestrogen receptor modulators, parathyroid hormone, the oestrogens and calcitonin2. In addition, the referent institutions and the specialists agree in including the practice of physical exercise among health-giving habits for people affected, or with possible affectation of bone mineralisation2. However, there is a need to evaluate longitudinal studies of physical exercise3, given that bone improvements happen 4-6 months after the start of intervention, but only after a year will these changes become significant3. Similarly, Beck et al.4 have found that, despite the abundant scientific evidence which relates resistance exercise with oestrogen stimulus, the changes in bone mineral density are usually modest. Therefore, it seems logical to think about the necessity of carrying out long term longitudinal studies to be able to observe changes resulting from the application of a resistance exercise programme

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Buscador

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Brief Original
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Index of Authors
Index of Communications
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Oral Communications
Original Articles
Osteology images
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