Treatment Of Osteoporosis In Patients Research Articles

Managing osteoporosis in COPD.

Chronic obstructive pulmonary disease (COPD) is a serious respiratory disease with high morbidity, disability and mortality worldwide. Every year, many people die from the disease or its comorbidities. Osteoporosis is a common complication of COPD, which can lead to increased fractures in COPD patients, aggravate the disease, and then bring great pain and burden to patients. The possible factors leading to osteoporosis in COPD patients include systemic inflammation, corticosteroid use, vitamin D deficiency, physical inactivity, tobacco exposure, lower bone mineral density, hypogonadism, hypoxia, and anemia. In clinical practice, the rate of diagnosis and treatment of osteoporosis in patients with COPD is low. Several studies demonstrated that treating osteoporosis with bisphosphonates could improve bone density, make breathing easier, and improve the quality of life of COPD patients. However, no studies have examined the effect of anti-osteoporosis therapy on fracture prevention in COPD patients. More research is needed to clarify how to implement holistic medical interventions in COPD patients with osteoporosis. We recommend that every COPD patient be screened for osteoporosis and treated with standard medications for primary osteoporosis.

#492 Ten-year experience treating osteoporosis with bisphosphonate in hemodialysis patients

Abstract Background and Aims The treatment of osteoporosis in patients undergoing hemodialysis (HD) has not been established, as there is insufficient evidence regarding the treatment of osteoporosis. The Kidney Disease: Improving Global Outcomes (KDIGO) 2017 guidelines suggest that determining the bone marrow density (BMD) of HD patients is useful. In 2011, we began treating HD patients' osteoporosis with alendronate. Herein, we describe the effects of the treatment based on our 10-year experience. Method This was a single-center prospective observational study of 85 HD patients (age 67.8 ± 11.0 yrs; 47 females, 38 males) treated for osteoporosis with alendronate at our hospital during the 10 years 2011–2021. The average observational period was 3.9 ± 2.9 years. The patients' BMD values including those at the lumbar spine, femoral neck, and total hip were determined by dual-energy X-ray absorptiometry. The patients whose first T-score was ≤ −2.5 were treated with alendronate. We evaluated the patients' yearly BMD measurements and their yearly values of bone metabolism markers, i.e., parathyroid hormone (PTH), bone alkaline phosphatase (BAP), and tartrate-resistant acid phosphatase 5b (TRACP-5b). Results We compared the data before and after the start of alendronate treatment by dividing the patients into a responder group (the patients whose T-score had improved at 1 year after treatment started; n=44) and a non-responder group (the patients whose T-score had not improved; n=32). The mean observational period of the responder group was significantly longer than that of the non-responder group (p<0.01). In a multiple regression analysis, a longer observational period was significantly associated with the improvement of T-scores (p=0.02). Only the mean T-score of the lumbar spine gradually improved during the study period; those of the femoral neck and total hip did not. Conclusion A long-term use of alendronate for the treatment of osteoporosis may be effective in hemodialysis patients, especially for the lumbar spine. Decisions regarding the effect of alendronate treatment for osteoporosis patients undergoing HD should not be made within only a year after the treatment initiation; rather, a longer observation period is necessary.

Guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis in pediatrics.

Objective. To provide a framework for healthcare professionals managing pediatric patients who are on active glucocorticoid (GC) therapy and to develop recommendations for the prevention and treatment of GC-induced osteoporosis in the pediatric population. Methods. A panel of experts on bone and pediatric diseases developed a series of PICO questions that address issues related to the prevention and treatment of osteoporosis in patients on GC therapy. In accordance with the GRADE approach, we conducted a systematic review of the literature, summarized effect estimations, and classified the quality of the evidence. Then, voting and the formulation of recommendations followed. Results. Seven recommendations and six general principles were developed for GC-induced osteoporosis in the pediatric population. Conclusion. These recommendations provide guidance for clinicians who must make decisions concerning pediatric patients undergoing treatment with GC.

Treatment of Osteoporosis after Hip Fracture: Survey of the Korean Hip Society.

To assess current practice in the treatment of osteoporosis in patients who underwent treatment for hip fracture in South Korea. A survey of 97 members of the Korean Hip Society, orthopedic hip surgeons who administer treatment for hip fractures in South Korea, was conducted. The survey was conducted for assessment of demographic data and perceptions regarding the management of osteoporosis in patients who have undergone treatment for hip fracture. Analysis of the data was performed using descriptive statistical methods. The majority of participants were between the age of 41 and 50 years, and 74% were practicing in tertiary hospitals. Testing for serum vitamin D levels (82%) was the most commonly performed laboratory test. Calcium and vitamin D were prescribed for more than 80% of patients by 47% and 52% of participants, respectively. Denosumab was the most commonly used first-line treatment option for osteoporosis in hip fracture patients. Bisphosphonate was most often perceived as the cause of atypical femoral fractures, and the most appropriate time for reoperation was postoperative 12 months. Teriparatide was most preferred after cessation of bisphosphonate and only prescribing calcium and vitamin D was most common in high-risk patients for prevention of atypical femoral fracture. The results of this study that surveyed orthopedic hip surgeons showed that most participants followed the current strategy for management of osteoporosis. Because the end result of osteoporosis is a bone fracture, active involvement of orthopedic surgeons is important in treating this condition.

OP70 Treating Patients With Hormone-Sensitive Cancer On Endocrine Therapy With Denosumab (Prolia®): A Systematic Review And Network Meta-Analysis

IntroductionPatients receiving endocrine therapy for hormone-sensitive cancers, such as men with prostate cancer (MPC) on hormone ablation therapy (HAT) and women with breast cancer (WBC) on adjuvant aromatase inhibitor therapy (AAIT), have an increased risk of developing osteoporosis. The aim of this study was to compare the safety and effectiveness of denosumab (Prolia®) with selective estrogen receptor modulators (SERMs) (raloxifene and bazedoxifene), bisphosphonates (zoledronate, ibandronate, alendronate, and risedronate), and placebo for the treatment of osteoporosis in patients receiving endocrine therapy for hormone-sensitive cancer.MethodsSystematic literature searches were conducted in three biomedical databases (PubMed, the Cochrane Library, and Embase) to identify randomized controlled trials (RCTs). Only RCTs that investigated MPC on HAT or WBC on AAIT allocated to denosumab, SERMs, bisphosphonates, or placebo were included. RCTs were appraised using the Cochrane Risk of Bias 2.0 tool. Frequentist network and pairwise meta-analyses were performed on predetermined outcomes of vertebral or nonvertebral fractures, treatment-related adverse events (AEs), bone mineral density (BMD), mortality, withdrawal due to treatment-related AEs, and serious AEs.ResultsA total of 14 RCTs (15 publications, 6,463 participants) were included. Relative to placebo, denosumab was found to prevent vertebral fractures in cancer patients receiving endocrine therapy. Moreover, denosumab, alendronate, and zoledronate increased femoral neck (FN) and lumbar spine (LS) BMD in MPC on HAT, compared with placebo, whereas denosumab, risedronate, and ibandronate improved LS and total hip BMD in WBC on AAIT. Similarly, denosumab and risedronate increased trochanteric BMD in WBC on AAIT, compared with placebo. In WBC on AAIT, only denosumab increased FN BMD relative to placebo.ConclusionsDenosumab was more effective than placebo in preventing vertebral fractures and improving BMD at the LS and FN in MPC on HAT, and in preventing vertebral fractures and improving FN, trochanteric, total hip, and LS BMD in WBC on AAIT. From a policy perspective, the continued reimbursement of denosumab needs to be reviewed.

Coronary artery calcification is associated with smaller increases in femoral neck bone mineral density with anti-resorptive therapy

Abstract Introduction Patients with osteoporosis are at high cardiovascular risk, partly due to vascular calcification, such as in the coronary vessels. It is uncertain if the presence of coronary artery calcification (CAC) effects bone mineral density (BMD) response to anti-resorptive treatment – first line therapy for osteoporosis. We therefore assessed changes in BMD following initiation of anti-resorptive treatment for osteoporosis in patients with and without evidence of CAC. Methods Individuals dispensed at least one prescription for an anti-resorptive medication (bisphosphonates or denosumab) at Monash Health between 2009-2022 were identified. Unique record numbers for these individuals were then cross-matched against the cardiac CT imaging service at Monash Heart (HREC#73603). CAC was detected using a 320-slice CT coronary angiogram (CTCA). We included only those patients having a baseline BMD measurement within two years of CTCA. The annualised percentage change in femoral neck BMD was calculated and adjusted for age, sex, height, weight, and number of years on anti-resorptive treatment. Results 106 individuals were identified of which 85 (women=70 [85%], median age=73 years [interquartile range 64-79 years]) had a follow-up BMD measurement including 19 with, and 66 without, evidence of CAC. Those with CAC were older (76 years versus 64 years, p<0.001). There were 70 bisphosphonate users and 15 denosumab users. Individuals with evidence of CAC experienced, on average, a 1.2% lower increase [(0.345% (0.343 to 0.348) versus -0.881% (-0.883 to -0.879), mean difference -1.226% (-1.493 to -0.959; p<0.05)] in annualised femoral neck BMD with anti-resorptive therapy after adjusting for important clinical risk factors. Interpretation These preliminary data suggests that CTCA-determined CAC may negatively impact femoral neck BMD increases with anti-resorptive therapy. This is perhaps consistent with existing and evolving hypotheses of dysregulatory processes driving ectopic calcium deposition, which we surmise would partially counter the effects of anti-resorptive therapy and potentially manifest as CAC. Thus, of particular interest will be the comparison of cardiovascular outcomes of patients with known CAC with and without anti-resorptive therapy, with the hypothesis that anti-resorptive therapy may potentially have cardioprotective effects in context of CAC. Analysis of the full cohort is underway.Table 1

26 Audit of osteoporosis treatment in patients undergoing Orthogeriatric rehabilitation

Abstract Background There was a perceived under-prescribing of osteoporosis treatment in this population. The transition from acute hospital to rehabilitation unit presented an opportunity to check medications and institute change. Methods Retrospective audit of patients’ medication charts. All patients on the rehabilitation ward under the care of an Ortho-geriatrician were included. Data was anonymised and recorded in an excel file. Prescription of calcium and vitamin D (single agent or combination) and targeted osteoporosis medications were recorded. Data collection performed by the specialist registrar on a ward round with the consultant. Interventions included education of Non-Consultant Hospital Doctors (NCHDs) to encourage proactive prescribing and documentation of the bone protection plan on the transfer summary. A re-audit was undertaken at a two month interval using the same methodology. Results 12 medication charts were examined as part of the initial audit. 10/12 had a neck of femur fracture and 2/12 had fragility fractures of the tibia/fibula requiring surgery. Zero patients were prescribed calcium alone, two vitamin D alone and 9/12 were on combination calcium and vitamin D. No patients were prescribed targeted osteoporosis treatment. 1/12 patients had a documented plan regarding bone protection. Re-audit examined 10 medication charts. 9/10 had a neck of femur fracture, 1/10 had a fracture of both the distal femur and the proximal humerus. Zero patients were prescribed calcium alone, three vitamin D alone and 6/10 were on combination calcium and vitamin D. 2/10 were prescribed oral bisphosphonate, 5/10 denosumab and 1/10 intravenous bisphosphonate. The remaining two patients did not yet have osteoporosis treatment prescribed. Conclusion Despite all of the initial patients being >14 days post-operative the majority did not have a plan or prescription for bone protection representing a missed opportunity to prevent further fractures. Re-audit post education demonstrated an 80% improvement in prescription of osteoporosis treatment.

Osteoporosis and diabetes - possible links and diagnostic difficulties.

In this review, the authors aimed to clarify the relationship between the occurrence of osteoporosis and diabetes, analyze the differences between the pathogenesis of osteoporosis in different types of diabetes and propose the most effective diagnostic strategy and fracture risk assessment in diabetic patients. A analysis of publications in MEDLINE, COCHRANE and SCOPUS databases was performed, searching for reports on the diagnostics, fracture risk assessment, prevention, and treatment of osteoporosis in patients with diabetes mellitus (DM) published in the years 2016-2022. The key words for the search were: diabetes, osteoporosis, and low-energy fracture. Bone complications of T1DM are more severe than T2DM, because of the lack of anabolic effect of insulin on bones. In T2DM the risk of fractures is elevated; however, identifying the mechanisms underlying the increased risk of fractures in T2DM is not clear. The FRAX tool is not appropriate for assessing the fracture risk in young patients with T1DM. It is quite useful in older patients with T2DM, but in these patients the calculated fracture risk may be underestimated. In T2DM the fracture risk often does not correspond to BMD value as measured by dual-energy X-ray absorptiometry (DXA). Diagnostic tools such as the trabecular bone score may play a significant role in this group of patients. Conclusions: Optimal strategies to identify and treat high risk individuals require further research and proper definition. The diagnostic criteria for osteoporosis should be clearly defined as well as fracture risk assessment and choice of anti-osteoporotic medication. In all cases of secondary osteoporosis, treatment of the underlying disease is the most important. The relationship between high risk of fractures and diabetes is inseparable, and its full understanding seems to be the key to effective management.

Effects of SIRT1 on Osteogenic Differentiation of Bone Marrow Mesenchymal Stem Cells in Type 2 Diabetic Patients.

Patients with type 2 diabetes mellitus (T2DM) are at high risk for osteoporosis. SIRT1 plays an important regulatory role in the occurrence and development of diabetes mellitus; however, it is still not clear whether SIRT1 is directly related to the osteogenic ability of bone marrow mesenchymal stem cells (BMSCs) in T2DM patients. We obtained BMSCs from patients with T2DM and healthy volunteers to determine the effect of SIRT1 expression on the osteogenic capacity of BMSCs. As a result, SIRT1 expression in BMSCs in T2DM was significantly lower compared to healthy volunteers, but the proliferative capacity of BMSCs in the T2DM group was not significantly different from that of healthy volunteers. During osteogenic differentiation, the expression of SIRT1 in MSCs from T2DM patients was significantly decreased, and the osteogenic differentiation ability of MSCs from T2DM patients was significantly lower than healthy volunteers. After intervention with resveratrol, the expression of SIRT1 increased significantly, and the apoptotic rate of MSCs in T2DM patients decreased significantly. Moreover, resveratrol promoted osteoblast differentiation of MSCs. Our study confirmed that the expression of SIRT1 is directly related to the osteogenic potential of BMSCs in patients with T2DM. Resveratrol promoted the osteogenic differentiation of BMSCs by increasing the expression of SIRT1. The increased expression of SIRT1 significantly reduced BMSC apoptosis during osteogenic differentiation, which is one of the important mechanisms by which SIRT1 regulates the osteogenic ability of BMSCs. Our data also provide strong evidence that resveratrol may be used in the treatment of osteoporosis in patients with T2DM.

Osteoporosis in patients with chronic liver disease: pathogenesis, diagnosis and treatment

Osteoporosis (OP) is a common complication in patients with chronic liver disease (CLD), which remains under the radar of clinicians. About 30% of patients with CLD suffer from OP. The increased risk of fractures in patients with CLD poses a serious socio-economic burden on the healthcare system and requires more effective measures of prevention, diagnosis, and treatment. The purpose of this review is to describe the pathophysiological mechanisms of OP development in CLD and existing diagnostic and therapeutic approaches in the management of such patients. The search in the PubMed database using the keywords "osteoporosis, bone disease, chronic liver diseases, liver cirrhosis" allowed us to select 42 sources published in 2001 – 2023. This review summarises potential mechanisms that underlie and may contribute to the development of OP in CLD. These include changes in vitamin D and calcium metabolism, vitamin K deficiency, hormonal dysregulation, the release of cytokines, sclerostin, changes in gut microbiota, deficiency of insulin-like growth factor-1 (IGF-1), and effects caused by drug intake. The prevalence, risk factors, diagnosis, screening strategies, and treatment of OP in patients with CLD are discussed.

Bad to the bones: prescribing of drugs for the prevention and treatment of osteoporosis in patients on chronic glucocorticoids.

This study aimed to identify a cohort of patients at risk for glucocorticoid-induced osteoporosis based on their prescribed glucocorticoid regimens and to quantify the proportion who were also prescribed osteoporosis pharmacologic treatment. The secondary objective was to recognize patient characteristics associated with receiving such treatment. A retrospective single-site cohort study used prescription order data to identify 7774 adults prescribed chronic glucocorticoids and measure the proportion also prescribed osteoporosis pharmacologic treatment. Of the total cohort, 1026/7774 (13.2%) had osteoporosis pharmacologic treatment prescribed. Of the subgroups prescribed a prednisone-equivalent of 5, 10, or 20mg per day or more for at least 180days, 584/4262 (13.7%), 153/1048 (14.6%), and 47/344 (13.7%) had treatment prescribed. Factors independently associated with osteoporosis pharmacologic treatment initiation included having osteoporosis or osteopenia on the problem list (OR = 4.45, 95% CI 3.70-5.34), history of dual-energy X-ray absorptiometry (DXA) screening (OR = 2.18, 95% CI 1.82-2.62), history of fracture (OR = 1.83, 95% CI 1.54-2.167), and longer duration of glucocorticoid use (OR = 1.33, 95% CI 1.10-1.59). The prescribing department was also a significant predictor of medication initiation, with cardiac transplant (OR = 6.04, 95% CI 3.97-9.17), oncology (OR = 4.11, OR 3.28-5.14), and lung transplant (OR = 1.51, 95% CI 1.08, 2.12) being positively correlated with this outcome, and nephrology (OR = 0.51, 95% CI 0.36-0.72) and kidney transplant (OR = 0.53, 95% CI 0.37, 0.75) being negatively correlated. Prescribing rate of osteoporosis pharmacologic treatment in patients using chronic glucocorticoids is low. Examining practices with higher prescribing rates may offer insight into improving protection against osteoporosis-induced fractures.

Trabecular bone score in rheumatic disease

Patients with rheumatic diseases (RD) are at high risk of osteoporosis (OP) and osteoporotic fractures. The Trabecular bone score (TBS) is a relatively novel method of assessing bone quality, which independently predicts fracture risk regardless of bone mineral density (BMD). A lower TBS in patients with RD compared to controls is shown in most studies concerning TBS and RD. The data obtained indicate that TBS predicts fractures better in RD, especially in patients receiving glucocorticoids, than BMD or the FRAX algorithm. TBS degradation has been associated with disease activity in ankylosing spondylitis, systemic sclerosis, and rheumatoid arthritis in a few studies. However, there is little data in the literature on the effect of rheumatic disease therapy and OP treatment in patients with RD on predictive ability of TBS for incident fracture.

Diagnosis and treatment of osteoporosis in patients with chronic kidney disease : Joint guidelines of the Austrian Society for Bone and Mineral Research (ÖGKM), the Austrian Society of Physical and Rehabilitation Medicine (ÖGPMR) and the Austrian Society of Nephrology (ÖGN)

Chronic kidney disease (CKD): abnormalities of kidney structure or function, present for over 3months. Staging of CKD is based on GFR and albuminuria (not graded). Osteoporosis: compromised bone strength (low bone mass, disturbance of microarchitecture) predisposing to fracture. By definition, osteoporosis is diagnosed if the bone mineral density T‑score is ≤ -2.5. Furthermore, osteoporosis is diagnosed if alow-trauma (inadequate trauma) fracture occurs, irrespective of the measured T‑score (not graded). The prevalence of osteoporosis, osteoporotic fractures and CKD is increasing worldwide (not graded). PATHOPHYSIOLOGY, DIAGNOSIS AND TREATMENT OF CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER (CKD-MBD): Definition of CKD-MBD: asystemic disorder of mineral and bone metabolism due to CKD manifested by either one or acombination of the following: abnormalities of calcium, phosphorus, PTH, or vitaminDmetabolism; renal osteodystrophy; vascular calcification (not graded). Increased, normal or decreased bone turnover can be found in renal osteodystrophy (not graded). Depending on CKD stage, routine monitoring of calcium, phosphorus, alkaline phosphatase, PTH and 25-OH-vitaminD is recommended (2C). Recommendations for treatment of CKD-MBD: Avoid hypercalcemia (1C). In cases of hyperphosphatemia, lower phosphorus towards normal range (2C). Keep PTH within or slightly above normal range (2D). VitaminDdeficiency should be avoided and treated when diagnosed (1C). Densitometry (using dual X‑ray absorptiometry, DXA): low T‑score correlates with increased fracture risk across all stages of CKD (not graded). Adecrease of the T‑score by 1unit approximately doubles the risk for osteoporotic fracture (not graded). AT-score ≥ -2.5 does not exclude osteoporosis (not graded). Bone mineral density of the lumbar spine measured by DXA can be increased and therefore should not be used for the diagnosis or monitoring of osteoporosis in the presence of aortic calcification, osteophytes or vertebral fracture (not graded). FRAX can be used to aid fracture risk estimation in all stages of CKD (1C). Bone turnover markers can be measured in individual cases to monitor treatment (2D). Bone biopsy may be considered in individual cases, especially in patients with CKD G5 (eGFR < 15 ml/min/1.73 m2) or CKD 5D (dialysis). Hypocalcemia should be treated and serum calcium normalized before initiating osteoporosis therapy (1C). CKD G1-G2 (eGFR ≥ 60 ml/min/1.73 m2): treat osteoporosis as recommended for the general population (1A). CKD G3-G5D (eGFR < 60 ml/min/1.73 m2 to dialysis): treat CKD-MBD first before initiating osteoporosis treatment (2C). CKD G3 (eGFR 30-59 ml/min/1.73 m2) with PTH within normal limits and osteoporotic fracture and/or high fracture risk according to FRAX: treat osteoporosis as recommended for the general population (2B). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) with osteoporotic fracture (secondary prevention): Individualized treatment of osteoporosis is recommended (2C). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) and high fracture risk (e.g. FRAX score > 20% for amajor osteoporotic fracture or > 5% for hip fracture) but without prevalent osteoporotic fracture (primary prevention): treatment of osteoporosis may be considered and initiated individually (2D). CKD G4-5D (eGFR < 30 ml/min/1.73 m2 to dialysis): Calcium should be measured 1-2weeks after initiation of antiresorptive therapy (1C). Resistance training prioritizing major muscle groups thrice weekly (1B). Aerobic exercise training for 40 min four times per week (1B). Coordination and balance exercises thrice weekly (1B). Flexibility exercise 3-7times per week (1B).

Trends in anti-osteoporotic medication utilization following fragility fracture in the USA from 2011 to 2019.

The aim of this study is to describe trends in the utilization of anti-osteoporotic medication after fragility fracture, including changes in the specific types of medications prescribed. Patients older than 65 with fragility fractures sustained from 2011 to 2019 were identified in the PearlDiver Patient Records Database. Osteoporosis treatment rate was defined as the rate at which patients were prescribed any of the fourteen most used anti-osteoporotic medications within 1year of fragility fracture. Fragility fractures were subcategorized by type. Treatment of fragility fractures was further stratified by patient demographics (age and gender) and medication type. This study showed an overall osteoporosis treatment rate of 8.01%, with treatment rates of 6.87% following hip fractures, 6.71% following upper extremity fractures, and 14.38% following vertebral compression fractures (VCF). From 2011 to 2018, there was no change in the overall fragility fracture treatment rate (p = 0.32). Of the three fracture categories analyzed, only the treatment rate for VCFs increased (p = 0.048). Osteoporosis treatment in patients with VCF increased among patients 65-74years old (p < 0.05) and male patients (p = 0.013). Treatment in patients with upper extremity fractures increased among patients 70-74years old (p = 0.038). Bisphosphonates were the most frequently prescribed class of medications. Bisphosphonates and denosumab increased in utilization (p = 0.049 and p < 0.001 respectively) while calcitonin utilization decreased (p < 0.001). Besides the overall low utilization rate of osteoporosis treatment in patients following fragility fractures, there has been no change in the treatment utilization rate within the past decade. More resources and interventions need to be enforced for all providers managing these patients if we are ever to address the osteoporosis epidemic.

The prevalence and treatment of osteoporosis in patients undergoing total hip arthroplasty and the levels of biochemical markers of bone turnover.

Osteoporosis is common in total hip arthroplasty (THA) patients. It plays a substantial factor in the surgery's outcome, and previous studies have revealed that pharmacological treatment for osteoporosis influences implant survival rate. The purpose of this study was to examine the prevalence of and treatment rates for osteoporosis prior to THA, and to explore differences in osteoporosis-related biomarkers between patients treated and untreated for osteoporosis. This single-centre retrospective study included 398 hip joints of patients who underwent THA. Using medical records, we examined preoperative bone mineral density measures of the hip and lumbar spine using dual energy X-ray absorptiometry (DXA) scans and the medications used to treat osteoporosis at the time of admission. We also assessed the following osteoporosis-related biomarkers: tartrate-resistant acid phosphatase 5b (TRACP-5b); total procollagen type 1 amino-terminal propeptide (total P1NP); intact parathyroid hormone; and homocysteine. The prevalence of DXA-proven hip osteoporosis (T-score ≤ -2.5) among THA patients was 8.8% (35 of 398). The spinal osteoporosis prevalence rate was 4.5% (18 of 398), and 244 patients (61.3%; 244 of 398) had osteopenia (-2.5 < T-score ≤ -1) or osteoporosis of either the hip or spine. The rate of pharmacological osteoporosis treatment was 22.1% (88 of 398). TRACP-5b was significantly lower in the osteoporosis-treated group than in the untreated group (p < 0.001). Osteoporosis is common in patients undergoing THA, but the diagnosis and treatment for osteoporosis were insufficient. The lower TRACP-5b levels in the osteoporosis-treated group - that is, osteoclast suppression - may contribute to the reduction of the postoperative revision rate after THA.Cite this article: Bone Joint Res2022;11(12):873-880.

Rapamycin regulates osteogenic differentiation through Parkin-mediated mitophagy in rheumatoid arthritis.

Varying degrees of bone destruction and bone loss occur in the development of rheumatoid arthritis (RA). Nevertheless, the mechanism underlying osteoporosis in the development of RA is not completely elucidated. Recent evidence indicates that mitophagy may play a vital role in regulating the differentiation and function of preosteoblast. Parkin is associated with mitophagy and various inflammatory diseases, but the precise role of Parkin in the treatment of osteoporosis in RA is unclear. In the present study, we found that the abnormal bone metabolism of RA is related to the activation of the mechanistic targets of mTORC1 pathway, and chronic inflammation which regulates the differentiation of preosteoblast through mitophagy. In this study, we found that Parkin was upregulated, and the mitochondrion was damaged in tumor necrosis factor alpha (TNF-α) stimulated preosteoblasts. Rapamycin (RAPA, an mTORC1 pathway blocker) upregulation of Parkin-mediated mitophagy tends to attenuate mitochondrial impairment caused by TNF-α in preosteoblasts. Theexperimentinvivo demonstrated that the combination therapy with TNF-α neutralizing antibody and RAPA significantly reduced osteoporosis in AIA mice. Drug inhibition of this pathway can be a potential treatment for osteoporosis in patients with RA.

Improving osteoporosis treatment rates in inpatients admitted with hip fracture: A healthcare improvement initiative in a tertiary referral hospital.

This healthcare improvement initiative was designed to increase inpatient osteoporosis treatment after hip fracture. A new protocol was developed by Geriatric Medicine and Endocrinology departments at a tertiary care hospital in Sydney. Its aim was to standardize assessment and treatment of osteoporosis in patients admitted with hip fracture. Eligible inpatients would receive intravenous zoledronic acid during their admission. A 6-month sample of hip fracture patients admitted after the protocol's implementation was compared to a group admitted before. Data collected included demographics, biochemistry, treatment rates, adverse effects, and admission survival. There was a considerable increase in osteoporosis treatment after introducing the protocol. Before the protocol's introduction, none of 36 eligible patients received treatment. After the intervention 79% (23 out of 29) of eligible patients were treated.All treated patients had renal function and serum calcium levels checked post-infusion with no adverse outcomes. Eight patients developed flu-like symptoms within 24 h of the infusion. There were no instances of arrhythmias, ocular inflammation, or death. The cost per patient treated was AUD $87. Adopting a standardized protocol for osteoporosis treatment in patients admitted for hip fracture was effective in improving treatment rates whilst being relatively safe and inexpensive.

PSAT182 Dilemmas in the Diagnosis and Management of Osteoporosis in a patient with Alkaptonuria: Successful Treatment with Teriparatide

Abstract Introduction Diagnosis and management of osteoporosis in patients with alkaptonuria can be challenging. Coexisting arthritis involving the lumbar spine (LS) and hips can falsely elevate bone density making DXA interpretation difficult. We report a patient with alkaptonuria who was successfully treated with teriparatide in addition to bisphosphonate therapy. Case History A 69-year-old female presented for evaluation of osteoporosis. She was diagnosed with alkaptonuria at age 29 when she reported bilateral conjunctival hyperpigmentation. She was also diagnosed with arthritis requiring left knee joint replacement at the age of 57 years. Subsequently, she underwent left hip, right knee, right hip, and left shoulder joint replacement surgeries. She also sustained fragility fractures in the foot and a 2-inches height loss. Physical examination: normal vital signs. Examination of eyes and ears: bluish black discoloration of the conjunctiva and ear lobes. Heart examination showed normal S1, split S2, and IV/VI systolic murmur over the right parasternal border; the rest of the physical examination revealed limited joint movements of thoracic and lumbar spines, wrists, ankles, knees and hip joints. Laboratory: serum PTH 33 pg./mL, 25-OH vitamins 28 ng/mL, 1,25 (OH)2 vitamin D 43 pg/mL, osteocalcin 11.6 mg/mL (ref 9.4-47.4), collagen cross-linked C-telopeptide 318 pg/mL (ref 104-1008), tyrosine 79.1 umol/L (ref 31.1-118.1), 24 hours urine homogentisic acid 4.2 gms (ref 20-30 mg). Genetic testing: compound heterozygous mutation for the HGD C. 496T2T&amp;gt;C and HGD C.1102A &amp;lt; G (p.mev368Va) variants, consistent with a diagnosis of alkaptonuria. DXA scan done at the age of 56 years showed osteoporosis (T score -2.7 femoral neck, 1.8 total hip, 2.5 LS). Patient was started on alendronate 70mg PO weekly for 5 years in addition to nitisinone. While on alendronate, she sustained fragility fractures of the right radius and left ankle. After 5 years of alendronate, the patient was transitioned to teriparatide 20-mcg subcutaneously (SC) daily for 2 years followed by annual intravenous zoledronic acid. For the subsequent 7 years, the patient led a healthy, active life with no fractures. Follow-up DXA showed improvement to the osteopenic range at the radius site as degenerative arthritis made interpretation of other sites impossible.This case illustrates the challenges in the diagnosis and treatment of osteoporosis in patients with alkaptonuria. DXA can be ineffective in this condition due to the hip and LS arthritis. Measurement of trabecular bone scoreS and CT of the LS may be better alternate choices. Bisphosphonates alone are typically not effective in preventing fragility fractures in this population but use of teriparatide may be an effective treatment. Further studies are needed to assess the effectiveness of teriparatide in this population but our case shows promise that this treatment result in BMD improvement and fracture prevention. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Effectiveness of Pharmacological Interventions for Treatment of Osteoporosis in Patients With CKD 3-5D: No Clear Choices

Fractures are a debilitating injury associated with extended rehabilitation, long-term pain, and considerable costs. Just half of patients with a hip fracture regain their mobility and their prefracture level of independence.1 As the population ages, predictions about increasing numbers of fractures are staggering: from 1.7 million fractures in 1990 to 6.3 million in 2050.2 Studies in patients with chronic kidney disease (CKD) stages 3 and 4 (CKD 3-4),3-6 on dialysis,7,8 and after transplantation9,10 all show that patients with CKD have a 2- to 100-fold increase in fracture risk compared to age- and sex-matched individuals without CKD.

Effects of hospitalist co-management on rate of initiation of osteoporosis treatment in patients with vertebral compression fractures: Retrospective cohort study

BackgroundVertebral compression fractures are common in elderly people and most are due to osteoporosis. Osteoporosis treatment is effective for secondary prophylaxis, so initiation is recommended. Despite the clear benefits, the rate of initiation of osteoporosis treatment is very low. It is reported to be due to several factors including insufficient systems-based approaches for hospitals and post-acute care. Hospitalists, who are physicians dedicated to the treatment of patients in hospital and whose activity is generalist rather than specialized, are reported to be associated with higher-quality inpatient care because of, among other things, closer adherence to guidelines. Co-management by hospitalists for patients with vertebral compression fractures has potential benefits towards improving the outcomes. We compared the rate of initiation of osteoporosis treatment for patients with vertebral compression fractures between conventional orthopedic surgeon-led care (conventional group) and hospitalist co-management care (co-management group). MethodsThis is a single-center retrospective cohort study to evaluate the rate of initiation of osteoporosis treatment and reasons for non-initiation of osteoporosis treatment. Other clinical indicators were also evaluated, including length of hospital stay, preventable complications during hospitalization, and rate of 30-day readmission. ResultsWe identified 55 patients in the conventional group and 93 patients in the co-management group. The rate of initiation of osteoporosis treatment was higher in the co-management group (45.2% vs. 3.6%, OR 21.5; 95%CI 5.12–192.0; P < 0.01). Most of the patients with non-initiation in the co-management group had reasons for it described in the medical records, but in the conventional group the reasons were unknown. There was no significant difference in length of hospital stay, preventable complications during hospitalization, or 30-day readmission between the groups. ConclusionsHospitalist co-management of patients with vertebral compression fractures showed significantly higher rate of initiation of osteoporosis treatment than conventional orthopedic surgeon-led care.