Osteoporosis: Diagnostic and Therapeutic Principles

289 Pages·1996·22.134 MB·English

by  Julie Glowacki PhD (auth.), Clifford J. Rosen MD (eds.)

OSTEOPOROSSI
CURRENT O CLINICAL O PRACTICE
Osteoporosis D: iagnostic and Therapeutic Principles,
edited by CLIFFORD J. ROSEN , 1996
Allergic Diseases :Diagnosis and Treatment,
edited by PHIL LIEBERMAN AND JOHN A. ANDERSON, 1996
OSTEOPOROSSI
DIAGNOSTIC AND THERAPEUTIC PRINCIPLES
Edited by
CLIFFORD J. ROSEN, MD
Maine Center for Osteoporosi sResearch
and Education ,St. Joseph Hospital Bangor ,Maine
SJ^ SPRINGER SCIENCE
+BUSINESS MEDIA , LL C
© 1996 Springer Science+Business Media New York
Originally published by Humana Press Inc. in 1996
Softcover reprint of the hardcover 1st edition 1996
For additional copies, pricing for bulk purchases, and/or information about other Humana titles,
contact Humana at the above address or at any of the following numbers: Tel.: [phone];
Fax: [phone]; E-mail: [email protected]
All rights reserved.
No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the
Publisher.
All articles, comments, opinions, conclusions, or recommendations are those of the authors), and do not necessarily reflect
the views of the publisher.
This publication is printed on acid-free paper. <S>
ANSI Z39.48-1984 (American National Standards Institute) Permanence of Paper for Printed Library Materials.
Photocopy Authorization Policy:
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted
by Springer Science+Business Media, LLC, provided that the base fee of US $5.00 per copy, plus US $00.25 per page,
is paid directly to the Copyright Clearance Center at 222 Rosewood Drive,Danvers,MA01923.Forthoseorganizations
that have been granted a photocopy license from the CCC, a separate system of payment has been arranged and is acceptable
to Springer Science+Business Media, LLC. The fee code for users of the Transactional Reporting Service is: [0-89603
-374-0/96 $5.00 + $00.25].
ISBN 978-1-4612-6668-6 ISBN 978-1-4612-0221-9 (eBook)
DOI 10.1007/978-1-4612-0221-9
FOREWORD
LA WRENCE G. RAISZ, MD
Division ofE ndocrinology and Metabolism,
University of Connecticut Health Center. Farmington. CT
The rapid transfer ofn ew knowledge concerning the pathogenesis, diagnosis, preven
tion, and treatment of disease into clinical practice has always been a major challenge in
medicine. This challenge is particularly difficult to meet in osteoporosis, not only because
there has been so much new knowledge generated in recent years, but also because this
disorder has not caught the attention of many practicing physicians. The goal of this
volume is to help primary care physicians develop a better understanding ofo steoporosis
and a more effective approach to diagnosis, prevention, and treatment. As primary care
physicians become more and more responsible for the maintenance of health and the
prevention of disease, osteoporosis must become one of their important concerns.
The magnitude of the problem of osteoporosis has been widely publicized. Within the
next 30 years, the cost ofh ip fractures alone is expected to exceed $40 billion a year in the
United States and will be a major cause ofincreased mortality. In addition, vertebral crush
fractures will cripple more and more ofo ur elderly population, both men and women. This
enormous toll is not inevitable. Current methods of identifying individuals at risk and
applying preventive programs could reduce the incidence offractures by 50% or more. This
should be the minimum goal of clinicians. We must identify and apply the principles and
practices that will achieve a substantial reduction in fracture incidence and disability at a
manageable cost. This will only occur if there is an effective dialog between health care
providers and those who are developing new approaches in osteoporosis.
There are other reasons for the substantial lag between the development ofn ew knowl
edge and its application in osteoporosis. One important reason is that there are many areas
of controversy. For example, there is still no general agreement about the role of screen
ing for osteoporosis or the costs and benefits of hormone replacement therapy. We still
are not sure about the relative efficacy ofd ifferent nonhormonal forms oft reatment. This
book will neither fully resolve nor avoid these controversies, but try to provide guidance
to the practicing physicians so that they can select the best alternatives for their patients.
As pointed out by Guyatt, we do not yet have the necessary information from extensive
prospective clinical trials that are available for other common disorders, for example, in
the treatment ofh ypertension. This is a common situation in medicine. Physicians make
decisions based on limited knowledge, but they can make better decisions if they have
ready access to the knowledge that is currently available. The aim of this book is to
provide that knowledge as well as the opinions of individuals who have worked exten
sively in this field. Thus, it will help the reader become acquainted with the fundamental
principles of bone biology, as well as the current understanding of pathogenetic mecha
nisms, clinical features, and therapy of osteoporosis.
One of the most controversial topics is diagnosis. It is easy to diagnose osteoporosis
in a patient with fractures. This is accomplished to a great extent by ruling out other
disorders that can mimic or aggravate osteoporosis. A more difficult, but potentially more
important, approach is to diagnose osteoporosis before fractures occur. Diagnostic cri
teria have been developed based on bone density, but there is not general agreement
v
vi Foreword
about the populations to be screened. Part III on "The Diagnosis of Osteoporosis" pro
vides guidelines for the clinical use of bone densitometry, while Part V provides a series
of "clinical scenarios," which cover many of the situations that the clinician is likely to
encounter in diagnosis as well as management.
How will this book be most useful to the clinician? First, a careful initial reading will
provide primary care physicians with a general understanding of osteoporosis and alert
them to considering this disorder as part of their routine evaluation of postmenopausal
women and go back again and again to review the practical aspects ofc linical interpretation
of bone densitometry and the treatment options described here. Finally, the clinical sce
narios will provide practical approaches to a number ofthe situations that clinicians encoun
ter repeatedly. In using these scenarios, it is important that clinicians recognize not only the
similarities, but the subtle variations in presentation among different patients and use the
breadth of opinion presented here to develop an appropriate plan of management.
Though we can provide a solid basis for clinical practice, its effectiveness will depend
on the commitment of primary care physicians not only to recognize this important
clinical problem, but also to keep up with this rapidly changing field. This is particularly
true for such topics as "Alternative Methods ofM easuring Bone Mass" and "Biochemical
Markers ofB one Turnover." New developments in these areas are occurring rapidly and
could evolutionize our approach to screening and diagnosis.
In addition, an increasing number of therapeutic options will soon become available.
New bisphosphonates and alternatives to estrogen as well as other agents are undergoing
clinical trials. These fresh approaches have already resulted in novel FDA-approved
drugs for the prevention and treatment of osteoporosis. Thus, throughout this text, the
authors have tried to provide the basis for evaluating new as well as established
approaches. Though fully confident that this first edition will be useful to its readers for
some time, I nonetheless expect that it will require revision in time. The preparation of
such a second edition will be guided not only by new developments in the field, but also
by the comments and criticisms of our readers. Thus, we hope that everyone who uses
this book will think about ways that it can be made clearer and more useful and com
municate their ideas to the Editor.
PREFACE
In the mid-1990s, the ultimate challenge facing health care providers is the quest for
comprehensive treatments for chronic diseases within a framework of reduced patient
access and limited financial resources. Osteoporosis is one ofthose diseases. Basic and
molecular studies of the skeletal remodeling system have produced a wealth of new
information about the osteoporotic process. Clinical studies employing new "bone spe
cific" agents have generated tremendous enthusiasm for newer therapeutic options, as
well as providing a greater understanding of the spectrum of metabolic bone diseases.
This expanded knowledge base has set the stage for even greater technological thrusts
aimed at earlier diagnoses and cost-effective treatments.
A simultaneous revolution in the provision ofA merican health care will crest well into
the next century. This tide will produce more primary care physicians, but reduce the
number of specialists and subspecialists. Additionally, because of limited financial
resources, there will be less opportunity for patients to seek consultations with "bone"
specialists. At the same time, the potential for universal coverage will mean that more
patients will enter the medical system earlier in the course oft heir disease. The complex
ity of care inherent in our delivery system, coupled with the flourishing of primary care
physicians, will present a major challenge f.or the proper management of chronic dis
eases. On the other hand, if we are to make a dent in the rising incidence of osteoporosis,
the battle should be carried to the forefront of medicine-the offices of primary care
providers.
The treatment of osteoporosis always begins with the message of prevention. This
theme is stressed in our metabolic bone clinic, whether for an 18-year-old girl with a
strong family history, or a 90-year-old man in a nursing home. To accomplish prevention
on a broader scale will require a tremendous educational effort, aimed not only at patients,
but also at primary care providers. Currently, little time is spent on the care and treatment
of patients with osteoporosis in the medical education process. For example, in medical
schools two weeks or less are committed to teaching the physiology ofthe musculosk
eletal system. Needless to say, within that time frame, studying rare genetic and meta
bolic syndromes occupies a more prominent place than understanding a very common
disorder. In postgraduate training programs the situation is not much better. Osteoporosis
is rarely discussed since it is primarily an "outpatient" disease. Often, when studied, this
disorder is considered part of the "aging" process, not as a separate pathophysiological
disorder. Finally, in subspecialty training, the management of metabolic bone disease
crosses many lines, thereby diluting its essence. Yet care of the osteoporotic women is
the province ofr heumatologists, endocrinologists, gynecologists, internists, family prac
titioners, physician extenders, nurse practitioners, and orthopedic surgeons.
The inspiration for Osteoporosis: Diagnostic and Therapeutic Principles came from
discussions, consultations, and lectures with primary care providers across the country.
Everywhere I traveled, providers agreed that a need existed for a clinically oriented book
about osteoporosis that would provide in-depth coverage of areas not often taught or
reviewed. Specifically, the sections on therapeutic intervention and interpretation of
bone densitometry are a direct result of hundreds (maybe thousands) of questions from
vii
viii Preface
providers at grand rounds and dinner meetings. The design of the treatment section was
also the result of input by family physicians and internists who felt the need, not to index
drugs, but rather to work through clinical scenarios. The extensive effort focusing on
quality of life and nondrug treatment options resulted from input by Drs. McClung,
Stock, Miller, and Ms. Love McClung and Ovedorff, members ofa "quality oflife" study
group. The section on clinical decision making by Dr. Guyatt represents a bold attempt
to have clinicians use an evidence-based approach to treat cases of osteoporosis. The
physiology and pathophysiology ofthis disease is complex and overwhelming. There
fore, I have added a glossary oft erms in hopes of providing clarity to some very difficult
issues.
Osteoporosis: Diagnostic and Therapeutic Principles is an effort to educate primary
care providers, students, house staff, endocrinologists, gynecologists, rheumatologists,
and orthopedic surgeons about the pathogenesis and treatment of osteoporosis. The con
tributors to this book were carefully chosen not for their fame or number of publications,
but because they were first and foremost clinician~octors who see patients with
osteoporosis. Yet, each author is, in his or her own right, a distinguished academician.
It is my fervent hope that Osteoporosis: Diagnostic and Therapeutic Principles will
help ensure that the proper evaluation and treatment of patients with osteoporosis can be
conducted by health care providers from all medical disciplines. Only through this mecha
nism can osteoporosis ultimately be prevented.
Clifford J. Rosen
CONTENTS
Foreword, by Lawrence G. Raisz, MD .................................................................. v
Preface ..................................................................................................... vii
Contributors .............................................................................................. xi
PART I. SKELETAL PHYSIOLOGY AND ITS RELEVANCE
TO OSTEOPOROSIS
1 The Cellular and Biochemical Aspects of Bone Remodeling ......... 3
Julie Glowacki
2 The Role of Calcium, Phosphorus, and Macronutrients
in the Maintenance of Skeletal Health ....................................... 17
John 1. B. Anderson
3 Vitamin D in Health and Prevention of Metabolic
Bone Disease .............................................................................. 29
Michael F. Holick
II.
PART THE PATHOPHYSIOLOGY OF OSTEOPOROSIS
4 The Pathophysiology of Osteoporosis ............................................ 47
Cathy R. Kessenich and Clifford 1. Rosen
5 The Epidemiology of Osteoporosis ................................................ 65
Michael Kleerekoper
6 Psychosocial Aspects of Osteoporosis ........................................... 69
Betsy Love McClung and Judith H. Overdoif
III.
PART THE DIAGNOSIS OF OSTEOPOROSIS
7 What Is an Osteoporotic Fracture? ................................................. 79
Richard Wasnich
8 Bone Densitometry Techniques in Modem Medicine ................... 89
Sydney Lou Bonnick
9 Clinical Interpretation and Utility of Bone Densitometry ........... 113
Paul D. Miller
10 Quantitative Ultrasound ................................................................ 121
Daniel T. Baran
11 Biochemical Markers of Bone Turnover ...................................... 129
Clifford 1. Rosen
Iv.
PART THE TREATMENT OF OSTEOPOROSIS
12 An Introduction to Clinical Decision Making in Osteoporosis ... 145
Gordon H. Guyatt
ix
x Contents
13 Calcium as a Primary Treatment and Prevention Modality
for Osteoporosis ........................................................................ 151
Robert Marcus
14 Use of Estrogen for Prevention and Treatment
of Osteoporosis ......................................................................... 159
Robert Marcus
15 Drug Therapy ................................................................................ 173
John L. Stock
16 Nonpharmacologic Therapy for Osteoporosis ............................. 189
Michael R. McClung and Kristi Spencer
V.
PART CASE PRESENTATIONS
17 Prevention of Osteoporosis ........................................................... 203
Robert M Levin
18 The Diagnosis and Treatment of Postmenopausal
Osteoporosis ............................................................................. 213
Clifford J. Rosen
19 The Approach to Osteoporosis in the Elderly Patient.. ................ 225
Douglas P. Kiel
20 Preventing and Treating Glucocorticoid Osteoporosis ................ 239
Robert A. Adler
21 Therapy for Osteoporosis in Men ................................................. 251
Eric S. Orwoll and Robert F. Klein
22 Bone Mass in Renal Disease ........................................................ 271
Paul D. Miller
23 Prevention of Osteoporosis: Making Sense of the Published
Evidence .................................................................................... 275
Peter S. Millard
Appendix 1: Glossary ................................................................... 287
Appendix 2: Costs of Diagnostic Tests and Treatments
of Osteoporosis ......................................................................... 291
Index .............................................................................................. 293