Prolonged steroid therapy leads to increased unfilled resorption cavities, reduced osteoid, thinned trabeculae, and decreased production of new bone during each re- modeling cycle. They also prevent calcium absorption from the gut and increase urinary calcium excretion re- sulting in negative calcium balance. All patients planned for prolonged steroid use should be fully evaluated for the risk of osteoporosis and should receive calcium and vitamin D supplements. These agents have been rec- ommended for better musculoskeletal health and may reduce the risk of fractures in patients using long-term steroids. 22,23 Studies using the bisphosphonates have clearly shown the great efficacy of these agents in reduc- ing the risk of steroid-induced osteoporosis and frac- tures. 24 Diagnosis and approach to patients The World Health Organization (WHO) operation- ally defines osteoporosis as bone density 2.5 standard deviations (SD) below the mean for young white adult women. This diagnostic criterion, however, does not apply to premenopausal women and children. The fol- low-up BMD should not be done before (on average) 1-and-a-half to 2 years after starting any intervention and whenever there is a need for follow-up. 25 Newer measures of bone strength, such as ultra- sound, have been introduced. Recent prospective studies using quantitative ultrasound (QUS) scan- ners perform nearly as well as DXA for assessing bone health. 26 These techniques, however, cannot be used for diagnosing or following up patients with osteopo- rosis. Information regarding the efficacy in young pre- menopausal or early menopausal women is lacking. Clinical trials of pharmacologic therapies have utilized DXA, rather than QUS, for entry criterion in studies, and there is uncertainty whether the results of these tri- als can be generalized to patients identified by QUS to have a high risk of fracture. Accordingly, DXA scanning is still the gold standard for assessing risk. Results from the various ultrasound devices (at least 6 commercial devices) are available and are not interchangeable. 27 The launch of WHO technical report: Assessment of osteoporosis at the primary health care level and the related FRAX tool has been a major milestone toward helping health professionals worldwide to improve the iden- tification of patients at high risk of fracture for treat- ment. 28-32 However, the FRAX assessment does not tell one absolutely whom to treat, which remains a matter of clinical judgment. In many countries, guidelines are provided that are based on the expert opinion and/or on health economic grounds. In the absence of the lo- cal data, the committee suggests continuing to use the index on a trial basis using the reliable data from the USA (White) version of the FRAX tool in the index until the local data becomes available. The FRAX tool can be reached through the web page: .
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- Winter '16
- The Land, postmenopausal osteoporosis