Initial Dual-energy X-ray Absorptiometry Research Articles

Bone health screening practices with dual-energy X-ray absorptiometry and prediction of abnormal results in pediatric inflammatory bowel disease.

Pediatric patients diagnosed with inflammatory bowel disease (IBD) are at risk of suboptimal peak bone mass attainment. This study aimed to understand rates of bone health screening adherence, describe factors associated with dual-energy X-ray absorptiometry (DXA) acquisition, and identify factors associated with abnormal DXA. We performed a retrospective cohort study of pediatric IBD patients over a 10-year time frame. We included IBD patients (2-20 years of age) enrolled in ImproveCareNow and excluded patients with primary metabolic bone disease. Time-to-event methods and multivariable logistic regression were employed to identify factors associated with DXA acquisition and abnormal DXA. In 676 patients, 464 (68.63%) pediatric patients with IBD had a risk factor for low bone mineral density (BMD); 137 (29.53%) underwent an initial DXA scan. Quiescent disease was significantly associated with a reduced likelihood of DXA (hazard ratio [HR]: 0.48; 95% confidence interval [CI]: 0.24-0.97), while weight z-score <-2 was significantly associated with DXA performance (HR: 2.07; 95% CI: 1.08-3.98). Abnormal DXA results (BMD z-score ≤-1) occurred in 59 (35.54%) individuals. After adjusting for visit diagnosis, delayed puberty, severe disease course, 6 months or greater of steroid exposure, and history of fracture, BMI z-score <-1 (odds ratio: 5.45; 95% CI: 2.41-12.33) was associated with abnormal DXA. DXA screening occurred in less than one-third of eligible pediatric IBD patients. Compliance was more common in patients with a weight z-score <-2 and less common in those with quiescent disease. BMI strongly predicted abnormal DXA results when adjusting for risk factors for abnormal BMD.

Prevalence and Risk Factors for Low Bone Mineral Density in Adults With Cystic Fibrosis.

Single-center studies have suggested that up to 70% of adults with cystic fibrosis (CF) have lower than expected bone mineral density (BMD), substantially higher than the 25% prevalence reported from national registries. We determined the prevalence of low BMD in CF adults at our center and assessed risk factors for low BMD. This retrospective cohort study was conducted in all CF patients ≥18 years of age who had a dual-energy X-ray absorptiometry (DXA) scan performed at the Johns Hopkins Adult Cystic Fibrosis center between 2010 and 2018. Prevalence and incidence of low BMD during the study period were determined. Poisson regression based on generalized estimating equations and robust standard errors were used to evaluate selected risk factors and risk of disease progression. A total of 234 individuals underwent an initial DXA scan. At this scan, prevalence of low BMD was 52.6% (95% confidence interval [CI] 46.0-59.1). A total of 43.6% were at risk for CF-related low BMD (AR-CFLBMD) (95% CI 37.1-50.2) and 9.0% had CF-related low BMD (CFRLBMD) (95% CI 5.6-13.4). Of the 25 with normal BMD at initial scan and a subsequent follow-up scan, 8 (32.0%) progressed to AR-CFLBMD. Of the 53 with AR-CFLBMD on initial scan and a subsequent scan, 6 (11.3%) progressed to CFLBMD, 9 (17.0%) returned to normal BMD, and 38 (71.7%) remained AR-CFLBMD. Older age (relative risk [RR]=1.01; 95% CI 1.00-1.01) and male sex (RR=1.32; 95% CI 1.04-1.66) were associated with increased risk of low BMD, while higher forced expiratory volume over 1 second (FEV1%) predicted (RR=0.99; 95% CI 0.99-1.00) and body mass index (BMI; RR=0.97; 95% CI 0.94-1.00) were associated with lower risk for low BMD. The fact that more than half of all individuals were found to have lower than expected BMD suggests that the actual prevalence may be higher than currently reported in national registries. This supports the importance of universal bone health screening of all CF adults. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Factors affecting bone mineral density in children and adolescents with secondary osteoporosis.

This study aimed to investigate the clinical factors associated with bone mineral density (BMD) among children and adolescents with osteoporosis secondary to treatment for underlying clinical conditions. We retrospectively reviewed the medical records of patients aged 10-18 years and evaluated them for lumbar spine BMD (LSBMD) after treatment for underlying diseases, including hemato-oncologic, rheumatologic system, and inflammator y bowel diseases. LSBMD measured by dual-energy x-ray absorptiometry (DXA) performed from March 2019 to March 2021 was evaluated. We analyzed 117 patients who underwent initial DXA after treatment for underlying diseases. Subjects in this study had multiple underlying diseases: hemato-oncologic (78.6%), rheumatologic (11.1%), and inflammatory bowel diseases (10.3%). There was no significant association between the z-score and bone metabolic markers (P&gt;0.05). However, higher cumulative glucocorticoid (GC) dose significantly reduced LSBMD z-score (P=0.029). Moreover, the association between cumulative dose of GC and initial z-score of LSBMD was significant in logarithmic regression analysis (P=0.003, R2=0.149). GC accumulation was a significant risk factor for vertebral fracture when the initial BMD was evaluated after treatment (P=0.043). Bone metabolic markers did not significantly influence the risk of vertebral fracture. Initial bone mass density of the lumbar spine evaluated after long-term GC use for underlying diseases is a predictor of further vertebral fractures.

Practice of Family Physicians in the Management of Osteoporosis Among Older Female Patients at King Abdulaziz Medical City, Riyadh, Saudi Arabia.

BackgroundOsteoporosis is one of the major worldwide health concerns and carries medical, social, and financial impacts due to its significant morbidity and mortality. The aim of this study was to explore the practice of family physicians in osteoporosis management in older female patients.MethodThis study was performed in a cross-sectional manner. Data, including patient and disease characteristics and management practices, were obtained from the electronic patient chart for female patients aged 60 years and older who were followed in family medicine clinics at King Abdulaziz Medical City, Riyadh, Saudi Arabia, during the period from January 1, 2018, to December 31, 2020. Management was checked and evaluated against osteoporosis management guidelines.ResultsIn 42 patients out of 250, an osteoporosis diagnosis was missed. Among the 208 charts that were reviewed, the mean patient age was 72.06 years, and the mean duration of the disease according to the initial dual-energy X-ray absorptiometry (DXA) scan was 3.68 years. Laboratory tests were performed for only about half of the patients. Vitamin D was given only to 54.3% while calcium supplements were given only to 53.4%. Almost one-third of the patients have not been prescribed any antiosteoporosis medications.ConclusionThe current study documented that older females with osteoporosis were not well-managed in the investigated family medicine settings. Continuous professional development activities and periodic practice reviews are suggested to improve this situation.

Use of Dual-Energy X-ray Absorptiometry in Children with Inflammatory Bowel Disease: A Large Single Centre Study.

Low bone mineral density (BMD) is a complication in children with inflammatory bowel disease (IBD). There are limited data evaluating dual-energy x-ray absorptiometry (DXA) as a screening tool for low BMD in children with IBD. We performed a single site retrospective analysis of DXA use. Children aged 5-18 years with IBD diagnosed between 2013 to 2017 at the Royal Children's Hospital, Australia, were included. Patient demographics, measures of disease activity, DXA scores, and factors related to BMD were collected. Over a median follow up of 5.1 (4-6.4) years, 72/239 (30.1%) children underwent DXA, and 28/239 (11.7%) children had a second DXA. Our DXA practice differed to consensus guidelines regarding initial screening based on height and/or body mass index (BMI) z-score (8/17 [47.1%]), and repeat surveillance (13/42 [31.0%]). Children had a median lumbar spine (LS) z-score -0.80 (-1.65-0.075). Children with LS z-score≤-2.0 (n=14) had lower weight (6.57 [1.78-23.7] vs. 51.1 [26.5-68.7], p=0.0002) and height centiles (3.62 [1.17-17.1] vs. 42 [16.9-67.1], p=0.0001), and higher faecal calprotectin (FCP) (3041 [1182-4192] vs. 585 [139-2419], p=0.009) compared to children with LS z-score>-2.0. No fractures were reported. Of 28 children who underwent a second DXA 1.6 (1.1-2.2) years following initial DXA, no significant change in z-scores occurred. Children with IBD had low BMD. In addition to height centile and weight centile, FCP was associated with lower BMD, and should be considered in DXA screening guidelines. Greater clinician awareness of DXA consensus guidelines is required. Future prospective studies are required.

SAT-369 Parathyroid Microadenomas as a Cause of Normocalcemic Primary Hyperparathyroidism (PHPT) and a Surgical Challenge

Background: Patients with normocalcemic primary hyperparathyroidism (PHPT) share similar risks of osteoporosis and nephrolithiasis with patients having hypercalcemic PHPT. The prevalence and natural history of normocalcemic PHPT is not well defined. Parathyroid microadenomas weighing < 100 mg may present as special clinical challenges in both the diagnosis and surgical resection.Clinical Case: A 55-year-old woman presented for an evaluation of osteoporosis following a non-traumatic L1 compression fracture at the age of 50 years. Noting an initial serum calcium of 10 mg/dL, we diagnosed her with normocalcemic PHPT based on a concurrent parathyroid hormone (PTH) level of 112 pg/mL (12-88 pg/mL) and a lack of other causes for an elevated PTH, including a normal eGFR, serum 25-hydroxyvitamin D, 24-hour urine calcium, and autoantibodies for celiac disease. Initial dual-energy x-ray absorptiometry (DXA) scan from 2015 showed normal bone mineral density (BMD) and T-scores in the L-spine, total hip, and femoral neck. Neck imagings, including ultrasound, sestamibi scan, and 4D CT, failed to localize a parathyroid adenoma. In the absence of a target and indications for parathyroidectomy other than osteoporosis, she was treated with bisphosphonates. While her serum calcium remained normal (9.6-10.2 mg/dL) despite an elevated PTH level (92-116 pg/mL) over a two-year period, subsequent DXA scans showed a significant loss in BMD on the bisphosphonates, prompting a peripheral DXA scan, which revealed severe osteoporosis at the distal third of the forearm (BMD 0.450 g/cm2, T-score -3.7), consistent with PTH-associated bone resorption. Following a 4-gland exploration with removal of 2 parathyroid microadenomas (63 and 100 mg), intra- and post-operative PTH levels normalized. She now awaits a repeat DXA scan at 1 year after a successful parathyroidectomy.Conclusion: Although many patients with normocalcemic PHPT may progress to develop hypercalcemia, some remain normocalcemic over an extended period. We report a patient who maintained normocalcemia for over 2 years. To correctly establish the diagnosis of normocalcemic PHPT, a comprehensive evaluation must be performed to exclude secondary causes of an elevated PTH (renal insufficiency, hypovitaminosis D, hypercalciuria, and malabsorption). Since significant osteoporosis may be preferentially seen in the cortical bone, BMD at the distal 1/3 of forearm should be evaluated in addition to the L-spine, hips and femoral necks. When a parathyroid adenoma cannot be localized in patients with normocalcemic PHPT, a careful 4-gland exploration for parathyroid microadenoma(s), paying special attention to the size, texture, and shape of the glands, and guided by intraoperative PTH levels, ensures the successful removal of the culprit gland(s).

MON-355 Charge Syndrome: Unusual Cause of Hypogonadism Leading to Osteoporosis

CHARGE syndrome is an unusual cause of hypogonadism; it is characterized by coloboma, heart defect, ateresia choanae, retarded growth and development, genital hypoplasia and ear anomalies. Two-thirds of affected patients have a mutation within the chromodomain helicase DNA-binding protein-7 gene, which is involved in embryonic development. The involvement of this gene in the pathogenesis of isolated idiopathic hypogonadotropic hypogonadism (HH) has been postulated. The reported incidence of this syndrome ranges from 0.1–0.2/10000 (1).A 24 year old female presented to our facility for further management of her HH and osteoporosis in the setting of her CHARGE syndrome. She was born full-term and diagnosed with this condition at the age of 6. Formal genetic testing as an adult demonstrated mutation within the CHD7 gene (chr 8:61,757,970). She had delayed puberty secondary to her hypogonadism; she was not treated with HRT as benefits were not considered significantly sufficient. She subsequently developed osteoporosis at the age of 20 which was treated at an outside facility with pamidronate IV Q4 months along with calcium and Vitamin D supplementation. Her initial Dual-energy X-ray absorptiometry (DXA) showed scoliosis in the lumbar spine [bone mass density (BMD): 0.514,osteoporosis by Z-score] with total hip showing BMD: 0.738,osteopenia by Z-score. Follow-up DXA after 3 years showed statistically significant improvement in bone mineralization of her L-spine [BMD: 0.595, +16%] and total hip [BMD: 0.777, +13.5%]. She presented to our facility in 2018 with labs showing normal calcium and 25-OH D; treatment with pamidronate was continued. She had a repeat DXA in 2019 which showed Z-scores of 0 in the left and right femoral necks. She was given the option of continued treatment for her osteoporosis versus monitoring and chose the latter with follow-up DXA.Hypogonadotropic hypogonadism is associated with delays in puberty or pubertal arrest. Luteinizing Hormone Releasing Hormone and HCG tests should be performed within the four months of life or at puberty in cases of hypogenitalism. GH deficiency should be investigated as a cause for growth retardation with GH stimulation levels. Hormone replacement is often required at puberty for females and is indicated for prevention of osteoporosis. Radiological testing with DXA scan should be included. Early proper endocrinological assessment and management is essential for adequate sexual development in these patients; this leads to improved overall quality of life along with prevention of serious morbidities, including bone demineralization (2).1. Blake K D, Prasad C. CHARGE syndrome. Orphanet Journal of Rare Diseases 2006, 1:34.2. Foppiani L, Maffe A. CHARGE syndrome as unusual cause of hypogonadism: endocrine and molecular evaluation. Andrologia (2010). 42: 326–330.

High detection rate of osteoporosis with screening of a general hospitalized population: a 6-year study in 6406 patients in a university hospital setting

BackgroundOsteoporosis is a highly prevalent disease identified by Dual Energy X-ray Absorptiometry (DEXA) that can be performed in an ambulatory (out-patient) or hospitalized population. We evaluated the use of baseline in-hospital DEXA screening to identify osteoporosis in ambulatory care and hospitalized patients; we also assessed specific risk factors for osteoporosis among these populations.MethodsWe included a baseline initial DEXA from 6406 consecutive patients at our tertiary referral University Hospital.ResultsOsteoporosis was diagnosed in 22.3% of the study population. In univariate analysis, osteoporosis risk factors were age, fracture history and low BMI (for all 3 sites), but also corticotherapy (lumbar spine and femoral neck) and male (lumbar spine). In multivariate analysis, age, fracture history, low BMI, and male increased osteoporosis risk. In-hospital screening yielded a higher percentage of osteoporosis positive scans than ambulatory care screening (31.8% vs 18.5%, p < 0.001). In-hospital screening targeted an older and more predominantly male population with a higher fracture history. Z-scores revealed that this difference was not only due to an older age of the population and mainly concerned cortical bone.ConclusionsIn-hospital osteoporosis screening revealed more osteoporosis than screening in ambulatory practice and could be an additional tool to improve the identification and management of osteoporosis. In addition to typical risk factors, we identified male gender as associated with osteoporosis detection in our cohort.

P214 Low bone mineral density in inflammatory bowel disease patients

Abstract Background Low bone mineral density (BMD) is an extra-intestinal manifestation and common complication of inflammatory bowel disease (IBD). There are many risk factors thought to contribute to this reduction in BMD but there is no clear consensus on screening for low BMD in IBD. This study was performed to determine the prevalence, screening strategy and risk factors for low BMD in the IBD population at a single tertiary centre. Methods Patients with IBD attending a single tertiary centre were included. Electronic medical records were reviewed and data on demographics, BMD assessments with dual-energy X-ray absorptiometry (DXA) scans as well as risk factors for low BMD were collected. BMD classification was in line with the World Health Organisation definitions. Multivariate analysis with logistic regression was used to compare variables. Results There were a total of 553 IBD patients; 281 (50.8%) were females and 364 (65.8%) had Crohn’s disease. Of the total cohort, 245 (44.3%) had a DXA scan performed. Of the 245 patients that had a DXA scan, 101 (41.2%) were defined as osteopenic, 16 (6.5%) were defined as osteoporotic and 128 (52.2%) had normal BMD. The average age of the DXA cohort at the time of scanning was 39 years old. There were 124 (50.6%) females and Crohn’s disease was present in 70.2% (n = 172) of the DXA cohort. The average BMI of the DXA cohort was 26.5 with a range of 16.5 to 59.1. The majority (n = 173; 70.6%) of the DXA cohort had reportedly never smoked with the rest being either current smokers (n = 35; 14.3%) or ex-smokers (n = 37; 15.1%) at the time of their scan. Follow up DXAs occurred in 34.6% of those 245 patients with an average time between scans of 4.6 years. In terms of the risk factors, gender was not found to be a significant risk factor (p = 0.085) along with the type of IBD (p = 0.174), steroid usage 20 mg/day in the 2 years prior to DXA scan (p = 0.886) and smoking history (p = 0.195). However, patients aged ≥50 years were more likely to have low BMD than patients aged &amp;lt;50 years (65.6% vs. 41.8%, p &amp;lt; 0.001). Similarly patients with a BMI &amp;lt;25.5 were more likely to have low BMD than patients with a BMI ≥25.5 25.5 (59.7% vs. 36.5%; p = 0.001). Conclusion We found a high prevalence of osteopenia (41%) but osteoporosis (6.5%) was uncommon in this IBD population from a single tertiary centre. Only age ≥50 years and BMI &amp;lt;25.5 were found to be significant risk factors for low BMD. Screening of this population was inconsistent with only 44% of the total cohort having an initial DXA scan and 35% of those who have an initial scan having a follow-up DXA scan. Local guidelines on screening for low bone mineral density are warranted.

Incidence and Predictors of Repeat Bone Mineral Densitometry: A Longitudinal Cohort Study.

Existing guidelines for repeat screening and treatment monitoring intervals regarding the use of dual-energy x-ray absorptiometry (DXA) scans are conflicting or lacking. The Choosing Wisely campaign recommends against repeating DXA scans within 2years of initial screening. It is unclear how frequently physicians order repeat scans and what clinical factors contribute to their use. To estimate cumulative incidence and predictors of repeat DXA for screening or treatment monitoring in a regional health system. Retrospective longitudinal cohort study PARTICIPANTS: A total of 5992 women aged 40-84years who received initial DXA screening from 2006 to 2011 within a regional health system in Sacramento, CA. Two- and five-year cumulative incidence and hazard rations (HR) of repeat DXA by initial screening result (classified into three groups: low or high risk of progression to osteoporosis, or osteoporosis) and whether women were prescribed osteoporosis drugs after initial DXA. Among women not treated after initial DXA, 2-year cumulative incidence for low-risk, high-risk, and osteoporotic women was 8.0%, 13.8%, and 19.6%, respectively, increasing to 42.9%, 60.4%, and 57.4% by 5years after initial screening. For treated women, median time to repeat DXA was over 3years for all groups. Relative to women with low-risk initial DXA, high-risk initial DXA significantly predicted repeat screening for untreated women [adjusted HR 1.67 (95% CI 1.40-2.00)] but not within the treated group [HR 1.09 (95% CI 0.91-1.30)]. Repeat DXA screening was common in women both at low and high risk of progression to osteoporosis, with a substantial proportion of women receiving repeat scans within 2years of initial screening. Conversely, only 60% of those at high-risk of progression to osteoporosis were re-screened within 5years. Interventions are needed to help clinicians make higher-value decisions regarding repeat use of DXA scans.

Long-term body composition changes in antiretroviral-treated HIV-infected individuals.

Body composition impacts physical function and mortality. We compared long-term body composition changes after antiretroviral therapy (ART) initiation in HIV-infected individuals to that in HIV-uninfected controls. Prospective observational study. We performed dual-energy x-ray absorptiometry (DXA) approximately 7.5 years after initial DXA in available HIV-infected individuals who received DXAs during the randomized treatment trial AIDS Clinical Trials Group A5202. For controls, we used DXA results from HIV-uninfected participants in the Boston Area Community Health/Bone and Women's Interagency HIV Study cohorts. Repeated measures analyses compared adjusted body composition changes between HIV-infected and HIV-uninfected individuals. Multivariable analyses evaluated factors associated with body composition change in HIV-infected individuals. We obtained DXA results in 97 HIV-infected and 614 HIV-uninfected participants. Compared with controls, HIV-infected individuals had greater adjusted lean mass and total, trunk, and limb fat gain during the first 96 weeks of ART. Subsequently, HIV-infected individuals lost lean mass compared with controls. Total, trunk, and limb fat gains after 96 weeks of ART slowed in HIV-infected individuals but remained greater than in controls. Lower CD4 T-cell count was associated with lean mass and fat gain during the initial 96 weeks of ART, but subsequently no HIV-related characteristic was associated with body composition change. Consistent with a 'return to health effect', HIV-infected individuals, especially those with lower baseline CD4 T-cell counts, gained more lean mass and fat during the first 96 weeks of ART than HIV-uninfected individuals. Continued fat gain and lean mass loss after 96 weeks may predispose HIV-infected individuals to obesity-related diseases and physical function impairment.

Bone mineral density screening and its accordance with Canadian clinical practice guidelines from 2000-2013: an unchanging landscape in Saskatchewan, Canada.

We examined the clinical characteristics of patients who underwent initial dual energy X-ray absorptiometry (DXA) testing at a primary care facility from 2000 to 2013, and whether these factors changed over time in accordance with Canadian clinical practice guidelines. The burden of osteoporosis remains high and largely unchanged and clinical practice guidelines are not being followed, overall. This study examined the clinical risk factors, therapeutic health behaviors, and bone mineral density (BMD) status of patients who underwent initial DXA testing at a primary care facility in Saskatchewan, Canada, and whether these factors changed over time from 2000 to 2013 in accordance with Canadian clinical practice guidelines. We conducted a retrospective cross-sectional medical chart audit of 800 patients 50years of age and older who underwent their first DXA test to assess BMD status. Data was extracted from 2000 to 2013 and further stratified into four periods (2000-2001, 2002-2006, 2007-2009, and 2010-2013; n = 200 each period) based on the years when practice guidelines were implemented. Extracted data included BMD outcomes, clinical risk factor indicators for DXA testing, and recommendations for therapeutic health behaviors outlined in the clinical practice guidelines. There were no differences in BMD status across the four time stratas (p = 0.430). Overall, most clinical risk factors had little change over time. The number of males screened significantly increased over time (p < 0.05), and osteoporosis drug therapy use decreased from 2000-2001 to 2010-2013 (p < 0.001). Increasing age, body mass <60kg, and history of adult fracture were significant independent predictors of osteoporosis diagnosis. The burden of osteoporosis remains high and largely unchanged in Saskatchewan, Canada. These results serve to inform strategies to enhance health-care provider awareness and compliance with practice guidelines, as well as improve screening rates and patient health behaviors.

AB0627 A randomized controlled trial of early initiation of osteoporosis assessment and management in the acute setting of the fracture clinic

BackgroundPatients with osteoporotic fractures have an increased likelihood of a future fracture. Only 3% to 5% of hip, wrist or vertebral fracture patients are diagnosed for osteoporosis (OP) and treated....

PP175-SUN CONSEQUENCES OF CATHETER-RELATED INFECTIONS IN PATIENTS WITH INTESTINAL FAILURE. RESULTS EXTRACTED FROM THE WORLD LARGEST SINGLE CENTER DATABASE

lead to a stabilisation or even an improvement of the bone mineral density (BMD) on the long range. Methods: Retrospective study of patients under HPN followed by the Gastroenterology Service of St-Luc Hospital from 2004 to 2011. Exclusion criteria were the lack of data on BMD or the absence of an osteodensitometry at the beginning of the HPN. Follow-up included regular visits with an endocrinologist, an initial dual energy X-ray absorptiometry at the start of HPN and every two years thereafter. BMD at the hip (g/cm2) were collected and their evolution was measured. A reduction or an increase in BMD was considered significant for a drop or a rise of 0.04 g/cm2 respectively. Results: 44 patients under HPN were identified. Data on BMD were collected for 30 individuals. A mean of 4 dual energy X-ray absorptiometry were performed for each patient. On average, we observed a drop of 0.01 g/cm2 (95% confidence interval (CI); drop of 0.03 rise of 0.01 g/cm2) in BMD for the entire follow-up. Globally, more than 70% of individuals showed a stabilisation or an increase in their BMD on the long range. It looks like there was no difference in the evolution of the bone status between people with osteoporosis initially and those without osteoporosis at the beginning of HPN. In addition, a small waiting time between the diagnosis of intestinal insufficiency and the beginning of HPN seems to ensure a better constancy of the BMD (odds ratio: 5.8; P value = 0.19). This trend seems similar when the duration of HPN was short (odds ratio: 4.5; P value = 0.16). Conclusion: An adequate follow-up of patients under HPN ensures a stabilisation of BMD on the long range.

Adjuvant aromatase inhibitors and bone health

Adjuvant hormonal therapy results in substantial improvements in disease-free and overall survival for women with operable breast cancer. Use of an aromatase inhibitor (AI) is expected to replace tamoxifen as standard care for many patients. Aromatase is the enzyme responsible for the final step in estrogen biosynthesis. This is the conversion of the androgens testosterone and androstenedione to the estrogens estrone and estradiol. AIs are potent inhibitors of estrogen production and thus one of the major concerns over their use is their effect on bone health and their potential to increase the incidence of osteoporosis and risk of fracture. The American Society of Clinical Oncology has recognized that these patients are at high risk of developing osteoporosis and has published guidelines to aid in their management. These recommend that all patients have an initial dual-energy X-ray absorptiometry (DEXA) bone scan to assess bone mineral density and are offered calcium and vitamin D supplements as well as lifestyle advice. Patients with osteoporosis should be treated with a bisphosphonate to reduce the incidence of fracture. Osteonecrosis of the jaws is a recently described adverse side-effect of bisphosphonate therapy and has been described in women with metastatic breast cancer. Oversuppression of bone turnover is probably the primary mechanism for the development of this condition. The degree of risk for osteonecrosis with bisphosphonates is uncertain and warrants careful monitoring.