Osteoarthritis

HARROGATE, ENGLAND — A mother's vitamin D status in late pregnancy is predictive of her offspring's lumbar spine volumetric bone density at age 9, a prospective study has shown.

The findings add to the growing body of evidence confirming that a woman's diet while pregnant can influence her child's later bone mass, said Nicholas W. Harvey, B.Chir.

The results of the population-based investigation also point to the potential efficacy of preventive measures to protect children's bone health, Dr. Harvey said in a presentation at the annual conference of the National Osteoporosis Society. “Vitamin D supplementation in pregnant women who are deficient may optimize peak accrual of bone mineral in their offspring,” he stated.

The investigation included 210 offspring of mothers enrolled in a larger cohort study of maternal nutrition and fetal development conducted by Dr. Harvey and his colleagues at the MRC environmental epidemiology unit of the University of Southampton (England). The mothers completed a questionnaire regarding their diet and lifestyle beginning from early pregnancy.

Anthropometric measures were recorded, including mid-upper arm circumference, which is a potential indicator of maternal nutritional status. The mothers gave venous blood samples in late pregnancy for the measurement of 25-hydroxyvitamin D levels and other nutrients. Concentrated umbilical cord blood was collected at birth to measure calcium, albumin, and phosphate.

The investigators recorded the size and weight of the offspring at birth. When the children reached age 9 years, they underwent dual-energy x-ray absorptiometry (DXA) for bone mass measurement. Because bone mineral density measured by DXA represents the areal density (grams per square centimeter) rather than the volumetric density (grams per cubic centimeter) of bone, the investigators generated mathematical estimates of volumetric bone density from the DXA measurements of bone mineral content and bone area.

“When studying bone mineral density during growth, the differences [between volumetric and areal BMD] have to be taken into consideration,” Dr. Harvey explained. As bones grow, the volume increases at a faster rate than the area, so the areal bone density will increase even if the volumetric density remains stable.

At 9 years, the boys in the study group (112) were significantly taller than the girls, and had higher age-adjusted lumbar spine bone mineral content and bone area but lower volumetric bone mineral density. After adjusting for child age and gender, maternal vitamin D was positively correlated with childhood volumetric BMD. “There was a threshold in the relationship, such that mothers in the lowest fifth of the [vitamin D] distribution had children with significantly lower volumetric bone mineral density at age 9 than those in the remaining four-fifths,” Dr. Harvey said.

Maternal mid-upper arm circumference and vitamin D supplementation in late pregnancy both had significant positive associations with volumetric BMD, while social class, maternal smoking and umbilical cord phosphate, calcium, and albumin levels did not. Calcium from the cord blood was predictive of increased bone mass, but not volumetric BMD, Dr. Harvey noted.

In a multivariate model, both maternal mid-upper arm circumference and low serum vitamin D remained significant predictors of childhood volumetric BMD status. The findings are especially timely, given that vitamin D deficiency is re-emerging as a significant problem among pregnant women and their infants, particularly among groups with dark skin or low skin exposure to sunlight, Dr. Harvey said. Checking a mother's vitamin D status and recommending sufficient supplementation for women who are deficient are simple steps “that could potentially reduce fractures in future generations,” he said.

HARROGATE, ENGLAND — A mother's vitamin D status in late pregnancy is predictive of her offspring's lumbar spine volumetric bone density at age 9, a prospective study has shown.

The findings add to the growing body of evidence confirming that a woman's diet while pregnant can influence her child's later bone mass, said Nicholas W. Harvey, B.Chir.

The results of the population-based investigation also point to the potential efficacy of preventive measures to protect children's bone health, Dr. Harvey said in a presentation at the annual conference of the National Osteoporosis Society. “Vitamin D supplementation in pregnant women who are deficient may optimize peak accrual of bone mineral in their offspring,” he stated.

The investigation included 210 offspring of mothers enrolled in a larger cohort study of maternal nutrition and fetal development conducted by Dr. Harvey and his colleagues at the MRC environmental epidemiology unit of the University of Southampton (England). The mothers completed a questionnaire regarding their diet and lifestyle beginning from early pregnancy.

Anthropometric measures were recorded, including mid-upper arm circumference, which is a potential indicator of maternal nutritional status. The mothers gave venous blood samples in late pregnancy for the measurement of 25-hydroxyvitamin D levels and other nutrients. Concentrated umbilical cord blood was collected at birth to measure calcium, albumin, and phosphate.

The investigators recorded the size and weight of the offspring at birth. When the children reached age 9 years, they underwent dual-energy x-ray absorptiometry (DXA) for bone mass measurement. Because bone mineral density measured by DXA represents the areal density (grams per square centimeter) rather than the volumetric density (grams per cubic centimeter) of bone, the investigators generated mathematical estimates of volumetric bone density from the DXA measurements of bone mineral content and bone area.

“When studying bone mineral density during growth, the differences [between volumetric and areal BMD] have to be taken into consideration,” Dr. Harvey explained. As bones grow, the volume increases at a faster rate than the area, so the areal bone density will increase even if the volumetric density remains stable.

At 9 years, the boys in the study group (112) were significantly taller than the girls, and had higher age-adjusted lumbar spine bone mineral content and bone area but lower volumetric bone mineral density. After adjusting for child age and gender, maternal vitamin D was positively correlated with childhood volumetric BMD. “There was a threshold in the relationship, such that mothers in the lowest fifth of the [vitamin D] distribution had children with significantly lower volumetric bone mineral density at age 9 than those in the remaining four-fifths,” Dr. Harvey said.

Maternal mid-upper arm circumference and vitamin D supplementation in late pregnancy both had significant positive associations with volumetric BMD, while social class, maternal smoking and umbilical cord phosphate, calcium, and albumin levels did not. Calcium from the cord blood was predictive of increased bone mass, but not volumetric BMD, Dr. Harvey noted.

In a multivariate model, both maternal mid-upper arm circumference and low serum vitamin D remained significant predictors of childhood volumetric BMD status. The findings are especially timely, given that vitamin D deficiency is re-emerging as a significant problem among pregnant women and their infants, particularly among groups with dark skin or low skin exposure to sunlight, Dr. Harvey said. Checking a mother's vitamin D status and recommending sufficient supplementation for women who are deficient are simple steps “that could potentially reduce fractures in future generations,” he said.

HARROGATE, ENGLAND — A mother's vitamin D status in late pregnancy is predictive of her offspring's lumbar spine volumetric bone density at age 9, a prospective study has shown.

The findings add to the growing body of evidence confirming that a woman's diet while pregnant can influence her child's later bone mass, said Nicholas W. Harvey, B.Chir.

The results of the population-based investigation also point to the potential efficacy of preventive measures to protect children's bone health, Dr. Harvey said in a presentation at the annual conference of the National Osteoporosis Society. “Vitamin D supplementation in pregnant women who are deficient may optimize peak accrual of bone mineral in their offspring,” he stated.

The investigation included 210 offspring of mothers enrolled in a larger cohort study of maternal nutrition and fetal development conducted by Dr. Harvey and his colleagues at the MRC environmental epidemiology unit of the University of Southampton (England). The mothers completed a questionnaire regarding their diet and lifestyle beginning from early pregnancy.

Anthropometric measures were recorded, including mid-upper arm circumference, which is a potential indicator of maternal nutritional status. The mothers gave venous blood samples in late pregnancy for the measurement of 25-hydroxyvitamin D levels and other nutrients. Concentrated umbilical cord blood was collected at birth to measure calcium, albumin, and phosphate.

The investigators recorded the size and weight of the offspring at birth. When the children reached age 9 years, they underwent dual-energy x-ray absorptiometry (DXA) for bone mass measurement. Because bone mineral density measured by DXA represents the areal density (grams per square centimeter) rather than the volumetric density (grams per cubic centimeter) of bone, the investigators generated mathematical estimates of volumetric bone density from the DXA measurements of bone mineral content and bone area.

“When studying bone mineral density during growth, the differences [between volumetric and areal BMD] have to be taken into consideration,” Dr. Harvey explained. As bones grow, the volume increases at a faster rate than the area, so the areal bone density will increase even if the volumetric density remains stable.

At 9 years, the boys in the study group (112) were significantly taller than the girls, and had higher age-adjusted lumbar spine bone mineral content and bone area but lower volumetric bone mineral density. After adjusting for child age and gender, maternal vitamin D was positively correlated with childhood volumetric BMD. “There was a threshold in the relationship, such that mothers in the lowest fifth of the [vitamin D] distribution had children with significantly lower volumetric bone mineral density at age 9 than those in the remaining four-fifths,” Dr. Harvey said.

Maternal mid-upper arm circumference and vitamin D supplementation in late pregnancy both had significant positive associations with volumetric BMD, while social class, maternal smoking and umbilical cord phosphate, calcium, and albumin levels did not. Calcium from the cord blood was predictive of increased bone mass, but not volumetric BMD, Dr. Harvey noted.

In a multivariate model, both maternal mid-upper arm circumference and low serum vitamin D remained significant predictors of childhood volumetric BMD status. The findings are especially timely, given that vitamin D deficiency is re-emerging as a significant problem among pregnant women and their infants, particularly among groups with dark skin or low skin exposure to sunlight, Dr. Harvey said. Checking a mother's vitamin D status and recommending sufficient supplementation for women who are deficient are simple steps “that could potentially reduce fractures in future generations,” he said.

SEATTLE — Bone mineral density measurements are equally good predictors of fracture risk in men and in women, even though men have a lower fracture risk, according to a 3-year study of almost 6,000 older men.

Previous studies have shown that bone mineral density (BMD) measurement predicts risk of fracture in women, but until now it has not been confirmed that the same is true for men, said Peggy M. Cawthon at the annual meeting of the American Society for Bone and Mineral Research.

The Osteoporotic Fractures in Men study found that men with osteoporosis had a 10-fold greater risk of non-spine fracture and a 100-fold greater risk of hip fracture, compared with men with normal BMD, said Ms. Cawthon, of the Research Institute, California Pacific Medical Center, San Francisco.

In the study, spine and hip BMD were measured in the men, whose average age was 74 years. Over the course of the study, there were 211 total non-spine fractures, 21 in the 104 men with osteoporosis, and 39 hip fractures, 10 in those with osteoporosis.

When the subjects were divided into quartiles based on their bone mineral density T scores, fracture rates increased as quartile decreased such that men in the lowest quartile of T score for the total hip had four times the risk of hip fracture of those in the highest quartile. The average T score for the cohort was -0.58.

Total hip density was a stronger predictor of hip fracture than was spine density, and femoral neck density, spine density, and total hip density were all similarly predictive of total non-spine fractures.

The correlations showed that the relative risk of hip fracture increased by 3.6 times with each lower, total hip T score standard deviation, Ms. Cawthon said. The relative risk of any fracture increased 1.8 times for each standard deviation of total hip T score.

In women, the relative risk of hip fracture and any non-spine fracture increases 2.6 times and 1.5 times, respectively, for each lower standard deviation. A comparison of the rate of fracture for any T score in this study with the rate of fracture in a similar study of women indicates a much higher rate of fracture in women, she added.

SEATTLE — Bone mineral density measurements are equally good predictors of fracture risk in men and in women, even though men have a lower fracture risk, according to a 3-year study of almost 6,000 older men.

Previous studies have shown that bone mineral density (BMD) measurement predicts risk of fracture in women, but until now it has not been confirmed that the same is true for men, said Peggy M. Cawthon at the annual meeting of the American Society for Bone and Mineral Research.

The Osteoporotic Fractures in Men study found that men with osteoporosis had a 10-fold greater risk of non-spine fracture and a 100-fold greater risk of hip fracture, compared with men with normal BMD, said Ms. Cawthon, of the Research Institute, California Pacific Medical Center, San Francisco.

In the study, spine and hip BMD were measured in the men, whose average age was 74 years. Over the course of the study, there were 211 total non-spine fractures, 21 in the 104 men with osteoporosis, and 39 hip fractures, 10 in those with osteoporosis.

When the subjects were divided into quartiles based on their bone mineral density T scores, fracture rates increased as quartile decreased such that men in the lowest quartile of T score for the total hip had four times the risk of hip fracture of those in the highest quartile. The average T score for the cohort was -0.58.

Total hip density was a stronger predictor of hip fracture than was spine density, and femoral neck density, spine density, and total hip density were all similarly predictive of total non-spine fractures.

The correlations showed that the relative risk of hip fracture increased by 3.6 times with each lower, total hip T score standard deviation, Ms. Cawthon said. The relative risk of any fracture increased 1.8 times for each standard deviation of total hip T score.

In women, the relative risk of hip fracture and any non-spine fracture increases 2.6 times and 1.5 times, respectively, for each lower standard deviation. A comparison of the rate of fracture for any T score in this study with the rate of fracture in a similar study of women indicates a much higher rate of fracture in women, she added.

SEATTLE — Bone mineral density measurements are equally good predictors of fracture risk in men and in women, even though men have a lower fracture risk, according to a 3-year study of almost 6,000 older men.

Previous studies have shown that bone mineral density (BMD) measurement predicts risk of fracture in women, but until now it has not been confirmed that the same is true for men, said Peggy M. Cawthon at the annual meeting of the American Society for Bone and Mineral Research.

The Osteoporotic Fractures in Men study found that men with osteoporosis had a 10-fold greater risk of non-spine fracture and a 100-fold greater risk of hip fracture, compared with men with normal BMD, said Ms. Cawthon, of the Research Institute, California Pacific Medical Center, San Francisco.

In the study, spine and hip BMD were measured in the men, whose average age was 74 years. Over the course of the study, there were 211 total non-spine fractures, 21 in the 104 men with osteoporosis, and 39 hip fractures, 10 in those with osteoporosis.

When the subjects were divided into quartiles based on their bone mineral density T scores, fracture rates increased as quartile decreased such that men in the lowest quartile of T score for the total hip had four times the risk of hip fracture of those in the highest quartile. The average T score for the cohort was -0.58.

Total hip density was a stronger predictor of hip fracture than was spine density, and femoral neck density, spine density, and total hip density were all similarly predictive of total non-spine fractures.

The correlations showed that the relative risk of hip fracture increased by 3.6 times with each lower, total hip T score standard deviation, Ms. Cawthon said. The relative risk of any fracture increased 1.8 times for each standard deviation of total hip T score.

In women, the relative risk of hip fracture and any non-spine fracture increases 2.6 times and 1.5 times, respectively, for each lower standard deviation. A comparison of the rate of fracture for any T score in this study with the rate of fracture in a similar study of women indicates a much higher rate of fracture in women, she added.

SAN DIEGO — Nearly half of adults with sickle cell anemia have osteopenia, according to results from a small study.

Although the exact cause of the association remains unclear, “iron overloading from blood transfusion may be a relevant contributing factor, as liver iron was significantly greater in osteopenic than nonosteopenic patients,” Farrukh T. Shah, M.D., said in a poster session at the annual meeting of the American Society of Hematology.

Other potential contributory mechanisms based on previous clinical research include marrow expansion, bone infarction, delayed puberty from anemia, low vitamin D levels, iron chelation therapy, and hypogonadism.

The investigators performed dual-energy x-ray absorptiometry (DEXA) scans on 10 female and 7 male consecutive sickle cell disease patients who had been transfused or were currently on a transfusion program. They also assessed hypogonadism, vitamin D3, parathyroid hormone, serum ferritin, and hemoglobin levels, said Dr. Shah of the department of hematology at Whittington Hospital NHS Trust, London.

Among females in the study, six had osteopenia or osteoporosis in the spine; four had significant demineralization of the hip (two osteoporotic, two osteopenic).

Liver iron concentrations were higher among osteopenic females than their nonosteopenic counterparts; the levels of serum estradiol were not different between the two groups. No differences were seen between the two groups in terms of ferritin, units of blood transfused, parathyroid hormone, or vitamin D.

Among males, two had spinal osteopenia but none had osteopenia of the hip. Liver iron levels and serum ferritin levels were higher in the osteopenic males than in the nonosteopenic males. No differences were noted between the two groups in terms of serum testosterone, units of blood transfused, parathyroid hormone, or vitamin D.

Overall, 47% of the study participants had osteopenia, Dr. Shah said.

SAN DIEGO — Nearly half of adults with sickle cell anemia have osteopenia, according to results from a small study.

Although the exact cause of the association remains unclear, “iron overloading from blood transfusion may be a relevant contributing factor, as liver iron was significantly greater in osteopenic than nonosteopenic patients,” Farrukh T. Shah, M.D., said in a poster session at the annual meeting of the American Society of Hematology.

Other potential contributory mechanisms based on previous clinical research include marrow expansion, bone infarction, delayed puberty from anemia, low vitamin D levels, iron chelation therapy, and hypogonadism.

The investigators performed dual-energy x-ray absorptiometry (DEXA) scans on 10 female and 7 male consecutive sickle cell disease patients who had been transfused or were currently on a transfusion program. They also assessed hypogonadism, vitamin D3, parathyroid hormone, serum ferritin, and hemoglobin levels, said Dr. Shah of the department of hematology at Whittington Hospital NHS Trust, London.

Among females in the study, six had osteopenia or osteoporosis in the spine; four had significant demineralization of the hip (two osteoporotic, two osteopenic).

Liver iron concentrations were higher among osteopenic females than their nonosteopenic counterparts; the levels of serum estradiol were not different between the two groups. No differences were seen between the two groups in terms of ferritin, units of blood transfused, parathyroid hormone, or vitamin D.

Among males, two had spinal osteopenia but none had osteopenia of the hip. Liver iron levels and serum ferritin levels were higher in the osteopenic males than in the nonosteopenic males. No differences were noted between the two groups in terms of serum testosterone, units of blood transfused, parathyroid hormone, or vitamin D.

Overall, 47% of the study participants had osteopenia, Dr. Shah said.

SAN DIEGO — Nearly half of adults with sickle cell anemia have osteopenia, according to results from a small study.

Although the exact cause of the association remains unclear, “iron overloading from blood transfusion may be a relevant contributing factor, as liver iron was significantly greater in osteopenic than nonosteopenic patients,” Farrukh T. Shah, M.D., said in a poster session at the annual meeting of the American Society of Hematology.

Other potential contributory mechanisms based on previous clinical research include marrow expansion, bone infarction, delayed puberty from anemia, low vitamin D levels, iron chelation therapy, and hypogonadism.

The investigators performed dual-energy x-ray absorptiometry (DEXA) scans on 10 female and 7 male consecutive sickle cell disease patients who had been transfused or were currently on a transfusion program. They also assessed hypogonadism, vitamin D3, parathyroid hormone, serum ferritin, and hemoglobin levels, said Dr. Shah of the department of hematology at Whittington Hospital NHS Trust, London.

Among females in the study, six had osteopenia or osteoporosis in the spine; four had significant demineralization of the hip (two osteoporotic, two osteopenic).

Liver iron concentrations were higher among osteopenic females than their nonosteopenic counterparts; the levels of serum estradiol were not different between the two groups. No differences were seen between the two groups in terms of ferritin, units of blood transfused, parathyroid hormone, or vitamin D.

Among males, two had spinal osteopenia but none had osteopenia of the hip. Liver iron levels and serum ferritin levels were higher in the osteopenic males than in the nonosteopenic males. No differences were noted between the two groups in terms of serum testosterone, units of blood transfused, parathyroid hormone, or vitamin D.

Overall, 47% of the study participants had osteopenia, Dr. Shah said.

NEW ORLEANS — Patients with vertebral fractures have a four- to fivefold higher risk for subsequent fragility fractures and should be targeted for aggressive therapy, Michael McClung, M.D., said at the annual meeting of the International Society for Clinical Densitometry.

“The combination of bone density testing and vertebral fracture assessment is a powerful combination as we attempt to stratify patients into those at very high risk who would clearly benefit from treatment,” added Dr. McClung of the Oregon Osteoporosis Center in Portland.

Both the severity and number of existing vertebral fractures are the best predictors of future vertebral fracture risk, regardless of bone density.

Payers are also starting to appreciate the benefit of assessing patients for such fractures. Medicare has agreed to reimburse physicians for vertebral fracture assessment (VFA) based on the new CPT code, 76077. Reimbursement is set at $43 and a referring physician must order the test. The International Society for Clinical Densitometry plans to take up the subject of VFA criteria at its position development conference later this year in Vancouver, B.C.

VFA is conducted using dual-energy x-ray absorptiometry and has a number of advantages that make it an attractive marker for evaluating an individual's future fracture risk. It's an in-office procedure, and the radiation dose required for VFA is substantially lower than for conventional radiographs. The whole spine is pictured in one image, not in a series, making it easier to read. The images are also digitized which allows for magnification and other image manipulation. The images can be archived and reviewed side by side with images from follow-up examinations.

The main drawback is that VFA resolution is lower than for conventional radiographs. In particular, the upper spine is harder to visualize because of artifacts related to the lungs and ribs.

VFA should be considered for:

▸ Women aged 65 years or older.

▸ Men aged 70 years or older.

▸ Patients with known height loss of at least 1.5 inches.

▸ Patients with a clinical history or nonradiologic assessment findings suggestive of vertebral fracture.

▸ Patients with bone density evidence of osteoporosis at the hip or spine.

▸ Patients with kyphosis on physical examination.

▸ Patients on long-term glucocorticoid therapy.

VFA is contraindicated during pregnancy. Nor is it recommended for the patient with recent spine x-ray for whom nothing has changed clinically.

As a rule, consider whether the diagnosis of vertebral fractures would alter the course of therapy, Dr. McClung said. VFA is not necessary in cases where the results wouldn't change the course of therapy.

Tips for Performing VFA

In performing VFA, the Genant semiquantitative method (see other box) provides a visual reference for grading fracture types (wedge, biconcave, or crush) and severity (mild, moderate, and severe).

Wedge compression fractures are more likely to occur in the thoracic spine, while bioconcave fractures are more likely to occur in the lumbar spine, Dr. McClung said.

Unless the resolution of the scan is very good, be cautious about diagnosing mild or grade 1 fractures using VFA alone, he added. This is particularly true of wedge fractures of the thoracic spine and biconcave fractures of the lumbar spine. But the technique is very good for identifying grades 2 and 3 fractures, which have more clinical significance.

There are a number of conditions that make it difficult to interpret VFA findings, including severe scoliosis, motion, rib/scapular shadows, bowel gas, and calcifications. Dr. McClung advises against making the diagnosis of osteoporotic fracture until the differential diagnoses are considered and the fracture cause identified.

In the event of uncertainty, “remember that this is not an x-ray and it's not meant to take the place of an x-ray. This is a very convenient way to make an assessment of vertebral deformity but we should not be reluctant, ashamed, or put off by saying 'I don't know what I see,'” he said.

If there's a question, get more information. Follow up with x-ray when there is an equivocal fracture; if vertebrae (T6-L4) are unidentifiable; if there are confounding factors or artifacts; or there are osteosclerotic, lytic, or suspect deformities. Also, get an x-ray if there are unspecified soft tissue or bone abnormalities.

NEW ORLEANS — Patients with vertebral fractures have a four- to fivefold higher risk for subsequent fragility fractures and should be targeted for aggressive therapy, Michael McClung, M.D., said at the annual meeting of the International Society for Clinical Densitometry.

“The combination of bone density testing and vertebral fracture assessment is a powerful combination as we attempt to stratify patients into those at very high risk who would clearly benefit from treatment,” added Dr. McClung of the Oregon Osteoporosis Center in Portland.

Both the severity and number of existing vertebral fractures are the best predictors of future vertebral fracture risk, regardless of bone density.

Payers are also starting to appreciate the benefit of assessing patients for such fractures. Medicare has agreed to reimburse physicians for vertebral fracture assessment (VFA) based on the new CPT code, 76077. Reimbursement is set at $43 and a referring physician must order the test. The International Society for Clinical Densitometry plans to take up the subject of VFA criteria at its position development conference later this year in Vancouver, B.C.

VFA is conducted using dual-energy x-ray absorptiometry and has a number of advantages that make it an attractive marker for evaluating an individual's future fracture risk. It's an in-office procedure, and the radiation dose required for VFA is substantially lower than for conventional radiographs. The whole spine is pictured in one image, not in a series, making it easier to read. The images are also digitized which allows for magnification and other image manipulation. The images can be archived and reviewed side by side with images from follow-up examinations.

The main drawback is that VFA resolution is lower than for conventional radiographs. In particular, the upper spine is harder to visualize because of artifacts related to the lungs and ribs.

VFA should be considered for:

▸ Women aged 65 years or older.

▸ Men aged 70 years or older.

▸ Patients with known height loss of at least 1.5 inches.

▸ Patients with a clinical history or nonradiologic assessment findings suggestive of vertebral fracture.

▸ Patients with bone density evidence of osteoporosis at the hip or spine.

▸ Patients with kyphosis on physical examination.

▸ Patients on long-term glucocorticoid therapy.

VFA is contraindicated during pregnancy. Nor is it recommended for the patient with recent spine x-ray for whom nothing has changed clinically.

As a rule, consider whether the diagnosis of vertebral fractures would alter the course of therapy, Dr. McClung said. VFA is not necessary in cases where the results wouldn't change the course of therapy.

Tips for Performing VFA

In performing VFA, the Genant semiquantitative method (see other box) provides a visual reference for grading fracture types (wedge, biconcave, or crush) and severity (mild, moderate, and severe).

Wedge compression fractures are more likely to occur in the thoracic spine, while bioconcave fractures are more likely to occur in the lumbar spine, Dr. McClung said.

Unless the resolution of the scan is very good, be cautious about diagnosing mild or grade 1 fractures using VFA alone, he added. This is particularly true of wedge fractures of the thoracic spine and biconcave fractures of the lumbar spine. But the technique is very good for identifying grades 2 and 3 fractures, which have more clinical significance.

There are a number of conditions that make it difficult to interpret VFA findings, including severe scoliosis, motion, rib/scapular shadows, bowel gas, and calcifications. Dr. McClung advises against making the diagnosis of osteoporotic fracture until the differential diagnoses are considered and the fracture cause identified.

In the event of uncertainty, “remember that this is not an x-ray and it's not meant to take the place of an x-ray. This is a very convenient way to make an assessment of vertebral deformity but we should not be reluctant, ashamed, or put off by saying 'I don't know what I see,'” he said.

If there's a question, get more information. Follow up with x-ray when there is an equivocal fracture; if vertebrae (T6-L4) are unidentifiable; if there are confounding factors or artifacts; or there are osteosclerotic, lytic, or suspect deformities. Also, get an x-ray if there are unspecified soft tissue or bone abnormalities.

NEW ORLEANS — Patients with vertebral fractures have a four- to fivefold higher risk for subsequent fragility fractures and should be targeted for aggressive therapy, Michael McClung, M.D., said at the annual meeting of the International Society for Clinical Densitometry.

“The combination of bone density testing and vertebral fracture assessment is a powerful combination as we attempt to stratify patients into those at very high risk who would clearly benefit from treatment,” added Dr. McClung of the Oregon Osteoporosis Center in Portland.

Both the severity and number of existing vertebral fractures are the best predictors of future vertebral fracture risk, regardless of bone density.

Payers are also starting to appreciate the benefit of assessing patients for such fractures. Medicare has agreed to reimburse physicians for vertebral fracture assessment (VFA) based on the new CPT code, 76077. Reimbursement is set at $43 and a referring physician must order the test. The International Society for Clinical Densitometry plans to take up the subject of VFA criteria at its position development conference later this year in Vancouver, B.C.

VFA is conducted using dual-energy x-ray absorptiometry and has a number of advantages that make it an attractive marker for evaluating an individual's future fracture risk. It's an in-office procedure, and the radiation dose required for VFA is substantially lower than for conventional radiographs. The whole spine is pictured in one image, not in a series, making it easier to read. The images are also digitized which allows for magnification and other image manipulation. The images can be archived and reviewed side by side with images from follow-up examinations.

The main drawback is that VFA resolution is lower than for conventional radiographs. In particular, the upper spine is harder to visualize because of artifacts related to the lungs and ribs.

VFA should be considered for:

▸ Women aged 65 years or older.

▸ Men aged 70 years or older.

▸ Patients with known height loss of at least 1.5 inches.

▸ Patients with a clinical history or nonradiologic assessment findings suggestive of vertebral fracture.

▸ Patients with bone density evidence of osteoporosis at the hip or spine.

▸ Patients with kyphosis on physical examination.

▸ Patients on long-term glucocorticoid therapy.

VFA is contraindicated during pregnancy. Nor is it recommended for the patient with recent spine x-ray for whom nothing has changed clinically.

As a rule, consider whether the diagnosis of vertebral fractures would alter the course of therapy, Dr. McClung said. VFA is not necessary in cases where the results wouldn't change the course of therapy.

Tips for Performing VFA

In performing VFA, the Genant semiquantitative method (see other box) provides a visual reference for grading fracture types (wedge, biconcave, or crush) and severity (mild, moderate, and severe).

Wedge compression fractures are more likely to occur in the thoracic spine, while bioconcave fractures are more likely to occur in the lumbar spine, Dr. McClung said.

Unless the resolution of the scan is very good, be cautious about diagnosing mild or grade 1 fractures using VFA alone, he added. This is particularly true of wedge fractures of the thoracic spine and biconcave fractures of the lumbar spine. But the technique is very good for identifying grades 2 and 3 fractures, which have more clinical significance.

There are a number of conditions that make it difficult to interpret VFA findings, including severe scoliosis, motion, rib/scapular shadows, bowel gas, and calcifications. Dr. McClung advises against making the diagnosis of osteoporotic fracture until the differential diagnoses are considered and the fracture cause identified.

In the event of uncertainty, “remember that this is not an x-ray and it's not meant to take the place of an x-ray. This is a very convenient way to make an assessment of vertebral deformity but we should not be reluctant, ashamed, or put off by saying 'I don't know what I see,'” he said.

If there's a question, get more information. Follow up with x-ray when there is an equivocal fracture; if vertebrae (T6-L4) are unidentifiable; if there are confounding factors or artifacts; or there are osteosclerotic, lytic, or suspect deformities. Also, get an x-ray if there are unspecified soft tissue or bone abnormalities.

Long-term bisphosphonate therapy can lead to osteonecrosis of the jaw —a previously unrecognized and potentially serious complication that can often be avoided, according to Salvatore Ruggiero, M.D., D.M.D.

Patients on intravenous therapy, whether for cancer or osteoporosis, face the highest risk regardless of whether they are taking the medication for cancer or for osteoporosis, while the risk is lower, although not absent in those taking oral bisphosphonates, said Dr. Ruggiero, who is chief of oral and maxillofacial surgery at Long Island Jewish Medical Center in New Hyde Park, NY.

“The push is to alert physicians that this is a potential problem, so that before they start a patient on bisphosphonates, they send them to a dentist to extract any teeth that are nonrestorable,” he told this newspaper. “Prevention and early detection are important for preserving the jawbone in these individuals.”

In his experience, the majority of cases have been associated with infections following dental surgeries such as tooth extractions.

However, necrosis has also occurred spontaneously in a significant number of patients, he said.

For this reason Dr. Ruggiero recommends that all patients on long-term bisphosphonates have two or three preventive dental visits per year, and that physicians be alert for any early signs of necrosis.

Patients should be alert to “things like tooth pain, swelling, numbness of the lip and chin, or pain within the jaw.

“This is not a very difficult diagnosis to make. You basically have to look in the mouth and if you see exposed bone it is very clear,” he said.

Dr. Ruggiero's research, published in the Journal of Oral and Maxillofacial Surgery (J. Oral Maxillofac. Surg. 62;2004:527-34), has prompted warnings from the Food and Drug Administration (FDA), as well as from Novartis, which manufactures the intravenous bisphosphonates pamidronate disodium (Aredia) and zoledronic acid (Zometa).

Novartis has also changed its package inserts to reflect this information. However, labeling for oral bisphosphonates has not changed.

His study identified 63 patients with osteonecrosis of the jaw (ONJ), all of whom were on long-term bisphosphonate therapy for a period ranging from 6 to 48 months.

Fifty-six of the patients had used intravenous bisphosphonates for cancer chemotherapy, while the remaining 7 had used oral bisphosphonates for treatment of osteoporosis.

Until these cases were identified, ONJ had been a rare clinical scenario, Dr. Ruggiero noted.

The typical presenting symptoms were pain and nonhealing exposed bone at the site of a previous tooth extraction. However, 9 patients (14%) had no history of a recent dentoalveolar procedure and presented with spontaneous exposure and necrosis of the alveolar bone. Biopsies of the lesions showed no evidence of metastatic disease, Dr. Ruggiero said.

The lesions had been refractory to conservative debridement procedures and antibiotic therapy.

The majority of patients required surgical procedures to remove all of the involved bone. These procedures included 45 sequestrectomies, 4 marginal mandibular resections, 6 segmental mandibular resections, 5 partial maxillectomies, and 1 complete maxillectomy. Despite these surgical procedures, 5 patients had persistent bone necrosis and developed new regions of exposed bone even after they stopped bisphosphonate therapy.

Dr. Ruggiero speculates that the impaired bone wound healing may result from a compromised vascular supply caused by the antiangiogenic effects of bisphosphonates. He suggests that the absence of bone problems elsewhere in the body may be due to the unique environment created by oral microflora.

Source: Dr. McHenry

Spontaneous jaw osteonecrosis can occur in patients treated with long-term bisphosphonates; however, the majority of cases occur after tooth extraction or other dental surgeries. Photos courtesy Salvatore Ruggiero, MD, DMD/Long Island Jewish Medical Center

Long-term bisphosphonate therapy can lead to osteonecrosis of the jaw —a previously unrecognized and potentially serious complication that can often be avoided, according to Salvatore Ruggiero, M.D., D.M.D.

Patients on intravenous therapy, whether for cancer or osteoporosis, face the highest risk regardless of whether they are taking the medication for cancer or for osteoporosis, while the risk is lower, although not absent in those taking oral bisphosphonates, said Dr. Ruggiero, who is chief of oral and maxillofacial surgery at Long Island Jewish Medical Center in New Hyde Park, NY.

“The push is to alert physicians that this is a potential problem, so that before they start a patient on bisphosphonates, they send them to a dentist to extract any teeth that are nonrestorable,” he told this newspaper. “Prevention and early detection are important for preserving the jawbone in these individuals.”

In his experience, the majority of cases have been associated with infections following dental surgeries such as tooth extractions.

However, necrosis has also occurred spontaneously in a significant number of patients, he said.

For this reason Dr. Ruggiero recommends that all patients on long-term bisphosphonates have two or three preventive dental visits per year, and that physicians be alert for any early signs of necrosis.

Patients should be alert to “things like tooth pain, swelling, numbness of the lip and chin, or pain within the jaw.

“This is not a very difficult diagnosis to make. You basically have to look in the mouth and if you see exposed bone it is very clear,” he said.

Dr. Ruggiero's research, published in the Journal of Oral and Maxillofacial Surgery (J. Oral Maxillofac. Surg. 62;2004:527-34), has prompted warnings from the Food and Drug Administration (FDA), as well as from Novartis, which manufactures the intravenous bisphosphonates pamidronate disodium (Aredia) and zoledronic acid (Zometa).

Novartis has also changed its package inserts to reflect this information. However, labeling for oral bisphosphonates has not changed.

His study identified 63 patients with osteonecrosis of the jaw (ONJ), all of whom were on long-term bisphosphonate therapy for a period ranging from 6 to 48 months.

Fifty-six of the patients had used intravenous bisphosphonates for cancer chemotherapy, while the remaining 7 had used oral bisphosphonates for treatment of osteoporosis.

Until these cases were identified, ONJ had been a rare clinical scenario, Dr. Ruggiero noted.

The typical presenting symptoms were pain and nonhealing exposed bone at the site of a previous tooth extraction. However, 9 patients (14%) had no history of a recent dentoalveolar procedure and presented with spontaneous exposure and necrosis of the alveolar bone. Biopsies of the lesions showed no evidence of metastatic disease, Dr. Ruggiero said.

The lesions had been refractory to conservative debridement procedures and antibiotic therapy.

The majority of patients required surgical procedures to remove all of the involved bone. These procedures included 45 sequestrectomies, 4 marginal mandibular resections, 6 segmental mandibular resections, 5 partial maxillectomies, and 1 complete maxillectomy. Despite these surgical procedures, 5 patients had persistent bone necrosis and developed new regions of exposed bone even after they stopped bisphosphonate therapy.

Dr. Ruggiero speculates that the impaired bone wound healing may result from a compromised vascular supply caused by the antiangiogenic effects of bisphosphonates. He suggests that the absence of bone problems elsewhere in the body may be due to the unique environment created by oral microflora.

Source: Dr. McHenry

Spontaneous jaw osteonecrosis can occur in patients treated with long-term bisphosphonates; however, the majority of cases occur after tooth extraction or other dental surgeries. Photos courtesy Salvatore Ruggiero, MD, DMD/Long Island Jewish Medical Center

Long-term bisphosphonate therapy can lead to osteonecrosis of the jaw —a previously unrecognized and potentially serious complication that can often be avoided, according to Salvatore Ruggiero, M.D., D.M.D.

Patients on intravenous therapy, whether for cancer or osteoporosis, face the highest risk regardless of whether they are taking the medication for cancer or for osteoporosis, while the risk is lower, although not absent in those taking oral bisphosphonates, said Dr. Ruggiero, who is chief of oral and maxillofacial surgery at Long Island Jewish Medical Center in New Hyde Park, NY.

“The push is to alert physicians that this is a potential problem, so that before they start a patient on bisphosphonates, they send them to a dentist to extract any teeth that are nonrestorable,” he told this newspaper. “Prevention and early detection are important for preserving the jawbone in these individuals.”

In his experience, the majority of cases have been associated with infections following dental surgeries such as tooth extractions.

However, necrosis has also occurred spontaneously in a significant number of patients, he said.

For this reason Dr. Ruggiero recommends that all patients on long-term bisphosphonates have two or three preventive dental visits per year, and that physicians be alert for any early signs of necrosis.

Patients should be alert to “things like tooth pain, swelling, numbness of the lip and chin, or pain within the jaw.

“This is not a very difficult diagnosis to make. You basically have to look in the mouth and if you see exposed bone it is very clear,” he said.

Dr. Ruggiero's research, published in the Journal of Oral and Maxillofacial Surgery (J. Oral Maxillofac. Surg. 62;2004:527-34), has prompted warnings from the Food and Drug Administration (FDA), as well as from Novartis, which manufactures the intravenous bisphosphonates pamidronate disodium (Aredia) and zoledronic acid (Zometa).

Novartis has also changed its package inserts to reflect this information. However, labeling for oral bisphosphonates has not changed.

His study identified 63 patients with osteonecrosis of the jaw (ONJ), all of whom were on long-term bisphosphonate therapy for a period ranging from 6 to 48 months.

Fifty-six of the patients had used intravenous bisphosphonates for cancer chemotherapy, while the remaining 7 had used oral bisphosphonates for treatment of osteoporosis.

Until these cases were identified, ONJ had been a rare clinical scenario, Dr. Ruggiero noted.

The typical presenting symptoms were pain and nonhealing exposed bone at the site of a previous tooth extraction. However, 9 patients (14%) had no history of a recent dentoalveolar procedure and presented with spontaneous exposure and necrosis of the alveolar bone. Biopsies of the lesions showed no evidence of metastatic disease, Dr. Ruggiero said.

The lesions had been refractory to conservative debridement procedures and antibiotic therapy.

The majority of patients required surgical procedures to remove all of the involved bone. These procedures included 45 sequestrectomies, 4 marginal mandibular resections, 6 segmental mandibular resections, 5 partial maxillectomies, and 1 complete maxillectomy. Despite these surgical procedures, 5 patients had persistent bone necrosis and developed new regions of exposed bone even after they stopped bisphosphonate therapy.

Dr. Ruggiero speculates that the impaired bone wound healing may result from a compromised vascular supply caused by the antiangiogenic effects of bisphosphonates. He suggests that the absence of bone problems elsewhere in the body may be due to the unique environment created by oral microflora.

Source: Dr. McHenry

Spontaneous jaw osteonecrosis can occur in patients treated with long-term bisphosphonates; however, the majority of cases occur after tooth extraction or other dental surgeries. Photos courtesy Salvatore Ruggiero, MD, DMD/Long Island Jewish Medical Center

SEATTLE — Vitamin D supplementation at twice the dose usually recommended for elderly individuals decreased falls in nursing home residents by 71%, Douglas P. Kiel, M.D., said at the annual meeting of the American Society for Bone and Mineral Research.

The usual dose of vitamin D recommended for bone health in elderly individuals is 400 IU a day. Vitamin D supplementation has been shown to decrease falls, but it is not certain if the usual dose is adequate for providing this benefit, said Dr. Kiel, director of medical research at the Hebrew Rehabilitation Center for Aged, Boston.

Dr. Kiel and his colleagues randomly assigned 125 elderly residents at a long-term care facility to one of four daily dosages of vitamin D, ranging up to 800 IU.

After 5 months, falls were reduced only among those who took the highest dose, Dr. Kiel noted in a poster presentation.

There were 9 falls among the 23 individuals who took 800 IU of vitamin D daily, compared with 31 falls among the 25 patients assigned placebo, 37 falls among 26 individuals who took 200 IU, 33 falls among 25 individuals who took 400 IU, and 41 falls among 25 individuals who took 600 IU.

The number of individuals who fell was also significantly reduced. Only 5 individuals taking 800-IU fell, compared with a range from 11 to 15 in the lower-dose and placebo groups.

Those figures translate into a three- to fourfold decrease in risk of falling for those who took the 800-IU dose of vitamin D, Dr. Kiel said.

Almost three-quarters of the individuals were already taking a multivitamin containing 400 IU of vitamin D, which could mean that the threshold dosage for preventing falls could be as high as 1,200 IU, Dr. Kiel noted.

The study subjects had a mean age of 89 years, and 72% were female.

SEATTLE — Vitamin D supplementation at twice the dose usually recommended for elderly individuals decreased falls in nursing home residents by 71%, Douglas P. Kiel, M.D., said at the annual meeting of the American Society for Bone and Mineral Research.

The usual dose of vitamin D recommended for bone health in elderly individuals is 400 IU a day. Vitamin D supplementation has been shown to decrease falls, but it is not certain if the usual dose is adequate for providing this benefit, said Dr. Kiel, director of medical research at the Hebrew Rehabilitation Center for Aged, Boston.

Dr. Kiel and his colleagues randomly assigned 125 elderly residents at a long-term care facility to one of four daily dosages of vitamin D, ranging up to 800 IU.

After 5 months, falls were reduced only among those who took the highest dose, Dr. Kiel noted in a poster presentation.

There were 9 falls among the 23 individuals who took 800 IU of vitamin D daily, compared with 31 falls among the 25 patients assigned placebo, 37 falls among 26 individuals who took 200 IU, 33 falls among 25 individuals who took 400 IU, and 41 falls among 25 individuals who took 600 IU.

The number of individuals who fell was also significantly reduced. Only 5 individuals taking 800-IU fell, compared with a range from 11 to 15 in the lower-dose and placebo groups.

Those figures translate into a three- to fourfold decrease in risk of falling for those who took the 800-IU dose of vitamin D, Dr. Kiel said.

Almost three-quarters of the individuals were already taking a multivitamin containing 400 IU of vitamin D, which could mean that the threshold dosage for preventing falls could be as high as 1,200 IU, Dr. Kiel noted.

The study subjects had a mean age of 89 years, and 72% were female.

SEATTLE — Vitamin D supplementation at twice the dose usually recommended for elderly individuals decreased falls in nursing home residents by 71%, Douglas P. Kiel, M.D., said at the annual meeting of the American Society for Bone and Mineral Research.

The usual dose of vitamin D recommended for bone health in elderly individuals is 400 IU a day. Vitamin D supplementation has been shown to decrease falls, but it is not certain if the usual dose is adequate for providing this benefit, said Dr. Kiel, director of medical research at the Hebrew Rehabilitation Center for Aged, Boston.

Dr. Kiel and his colleagues randomly assigned 125 elderly residents at a long-term care facility to one of four daily dosages of vitamin D, ranging up to 800 IU.

After 5 months, falls were reduced only among those who took the highest dose, Dr. Kiel noted in a poster presentation.

There were 9 falls among the 23 individuals who took 800 IU of vitamin D daily, compared with 31 falls among the 25 patients assigned placebo, 37 falls among 26 individuals who took 200 IU, 33 falls among 25 individuals who took 400 IU, and 41 falls among 25 individuals who took 600 IU.

The number of individuals who fell was also significantly reduced. Only 5 individuals taking 800-IU fell, compared with a range from 11 to 15 in the lower-dose and placebo groups.

Those figures translate into a three- to fourfold decrease in risk of falling for those who took the 800-IU dose of vitamin D, Dr. Kiel said.

Almost three-quarters of the individuals were already taking a multivitamin containing 400 IU of vitamin D, which could mean that the threshold dosage for preventing falls could be as high as 1,200 IU, Dr. Kiel noted.

The study subjects had a mean age of 89 years, and 72% were female.

NEW ORLEANS — Very elderly Americans are rarely assessed and treated for low bone density and osteoporosis despite significant potential benefits, experts said at the annual meeting of the International Society for Clinical Densitometry.

“It's the oldest old, those over age 85,” whose numbers are increasing most dramatically. “In fact, people over 100—the centenarians—are the fastest growing group of Americans,” said Neil Binkley, M.D., of the University of Wisconsin, Madison.

Bone loss happens faster in the very elderly than in the less elderly, resulting in higher prevalence rates of osteoporosis, hip fractures, and other serious fractures, said Michael McClung, M.D., of the Oregon Osteoporosis Center, Portland.

Yet despite these risks, the rates of bone density screening go down as age increases, Dr. Binkley said. “We aren't doing a very good job of paying attention to elderly patients,” Dr. McClung agreed.

The very elderly tend to fall into two groups: the ambulatory and reasonably healthy and nursing home residents, who tend to be in poor health and not ambulatory. Virtually all nursing home residents have osteoporosis or low bone density and a very high risk of fractures. Yet these patients rarely receive even calcium and vitamin D supplementation.

The cost of withholding such basic interventions is huge. For the current population of roughly 1,600,000 nursing home residents, the cost of hip fractures is about $700 million per year, assuming an annual hip fracture rate of 2.3% and a cost of $18,500 per hip fracture.

In deciding how to care for these patients, it's helpful to divide them into three groups, Dr. Binkley said. Some patients come to nursing homes for terminal care and these patients probably won't benefit from osteoporosis treatment. A number of patients come to nursing homes for rehabilitation following a hip fracture and these people should be treated for low bone density and osteoporosis.

The third group poses the real treatment challenge: long-term care patients who are in nursing homes because of cognitive decline or the need for help with daily living tasks. There are no data on the effectiveness of treatments for this type of patient. “The easy answer might be that we ensure that they have adequate calcium intake and give them vitamin D,” Dr. Binkley said.

Vitamin D supplementation, in particular, “is an incredibly cost-effective way to intervene,” Dr. McClung agreed. Vitamin D deficiency is very common in the elderly, even in those who still have good mobility. “The older we get, the more dependent we are on higher levels of vitamin D to maintain calcium homeostasis.”

Dr. McClung added that in his own clinic, individuals over the age of 70 are given a 50,000-U dose of vitamin D taken once a month. Study results have suggested that 400 IU of vitamin D per day may not be adequate for many older individuals.

Although a number of drugs have been shown to reduce fracture risk in osteoporotic patients, most of the trials have not involved patients over the age of 80.

Given the lack of supportive data, deciding whether to use bisphosphonates in nursing home residents, however, is tricky.

“My approach, in the absence of data, is to utilize cognition,” Dr. Binkley said. He asks patients if this type of treatment is feasible in their living situation, and he inquires about their desire to take the drug, and how their family feels about the approach. If the responses are favorable, he prescribes a bisphosphonate.

Six Tips to Prevent Fractures

▸ Measure bone density and diagnose osteoporosis in this age group.

▸ Think beyond age: General health and frailty may be better predictors of fracture risk.

▸ Bisphosphonates actually work quickly, and patients will see a benefit.

▸ Anticipate vitamin D deficiencies: High doses are acceptable in this population.

▸ Age is not a barrier to drug response.

▸ Drugs are not the only interventions: Exercise, tools for daily living, and training to prevent falls are effective as well.

Sources: Dr. Binkley, and Dr. McClung.

NEW ORLEANS — Very elderly Americans are rarely assessed and treated for low bone density and osteoporosis despite significant potential benefits, experts said at the annual meeting of the International Society for Clinical Densitometry.

“It's the oldest old, those over age 85,” whose numbers are increasing most dramatically. “In fact, people over 100—the centenarians—are the fastest growing group of Americans,” said Neil Binkley, M.D., of the University of Wisconsin, Madison.

Bone loss happens faster in the very elderly than in the less elderly, resulting in higher prevalence rates of osteoporosis, hip fractures, and other serious fractures, said Michael McClung, M.D., of the Oregon Osteoporosis Center, Portland.

Yet despite these risks, the rates of bone density screening go down as age increases, Dr. Binkley said. “We aren't doing a very good job of paying attention to elderly patients,” Dr. McClung agreed.

The very elderly tend to fall into two groups: the ambulatory and reasonably healthy and nursing home residents, who tend to be in poor health and not ambulatory. Virtually all nursing home residents have osteoporosis or low bone density and a very high risk of fractures. Yet these patients rarely receive even calcium and vitamin D supplementation.

The cost of withholding such basic interventions is huge. For the current population of roughly 1,600,000 nursing home residents, the cost of hip fractures is about $700 million per year, assuming an annual hip fracture rate of 2.3% and a cost of $18,500 per hip fracture.

In deciding how to care for these patients, it's helpful to divide them into three groups, Dr. Binkley said. Some patients come to nursing homes for terminal care and these patients probably won't benefit from osteoporosis treatment. A number of patients come to nursing homes for rehabilitation following a hip fracture and these people should be treated for low bone density and osteoporosis.

The third group poses the real treatment challenge: long-term care patients who are in nursing homes because of cognitive decline or the need for help with daily living tasks. There are no data on the effectiveness of treatments for this type of patient. “The easy answer might be that we ensure that they have adequate calcium intake and give them vitamin D,” Dr. Binkley said.

Vitamin D supplementation, in particular, “is an incredibly cost-effective way to intervene,” Dr. McClung agreed. Vitamin D deficiency is very common in the elderly, even in those who still have good mobility. “The older we get, the more dependent we are on higher levels of vitamin D to maintain calcium homeostasis.”

Dr. McClung added that in his own clinic, individuals over the age of 70 are given a 50,000-U dose of vitamin D taken once a month. Study results have suggested that 400 IU of vitamin D per day may not be adequate for many older individuals.

Although a number of drugs have been shown to reduce fracture risk in osteoporotic patients, most of the trials have not involved patients over the age of 80.

Given the lack of supportive data, deciding whether to use bisphosphonates in nursing home residents, however, is tricky.

“My approach, in the absence of data, is to utilize cognition,” Dr. Binkley said. He asks patients if this type of treatment is feasible in their living situation, and he inquires about their desire to take the drug, and how their family feels about the approach. If the responses are favorable, he prescribes a bisphosphonate.

Six Tips to Prevent Fractures

▸ Measure bone density and diagnose osteoporosis in this age group.

▸ Think beyond age: General health and frailty may be better predictors of fracture risk.

▸ Bisphosphonates actually work quickly, and patients will see a benefit.

▸ Anticipate vitamin D deficiencies: High doses are acceptable in this population.

▸ Age is not a barrier to drug response.

▸ Drugs are not the only interventions: Exercise, tools for daily living, and training to prevent falls are effective as well.

Sources: Dr. Binkley, and Dr. McClung.

NEW ORLEANS — Very elderly Americans are rarely assessed and treated for low bone density and osteoporosis despite significant potential benefits, experts said at the annual meeting of the International Society for Clinical Densitometry.

“It's the oldest old, those over age 85,” whose numbers are increasing most dramatically. “In fact, people over 100—the centenarians—are the fastest growing group of Americans,” said Neil Binkley, M.D., of the University of Wisconsin, Madison.

Bone loss happens faster in the very elderly than in the less elderly, resulting in higher prevalence rates of osteoporosis, hip fractures, and other serious fractures, said Michael McClung, M.D., of the Oregon Osteoporosis Center, Portland.

Yet despite these risks, the rates of bone density screening go down as age increases, Dr. Binkley said. “We aren't doing a very good job of paying attention to elderly patients,” Dr. McClung agreed.

The very elderly tend to fall into two groups: the ambulatory and reasonably healthy and nursing home residents, who tend to be in poor health and not ambulatory. Virtually all nursing home residents have osteoporosis or low bone density and a very high risk of fractures. Yet these patients rarely receive even calcium and vitamin D supplementation.

The cost of withholding such basic interventions is huge. For the current population of roughly 1,600,000 nursing home residents, the cost of hip fractures is about $700 million per year, assuming an annual hip fracture rate of 2.3% and a cost of $18,500 per hip fracture.

In deciding how to care for these patients, it's helpful to divide them into three groups, Dr. Binkley said. Some patients come to nursing homes for terminal care and these patients probably won't benefit from osteoporosis treatment. A number of patients come to nursing homes for rehabilitation following a hip fracture and these people should be treated for low bone density and osteoporosis.

The third group poses the real treatment challenge: long-term care patients who are in nursing homes because of cognitive decline or the need for help with daily living tasks. There are no data on the effectiveness of treatments for this type of patient. “The easy answer might be that we ensure that they have adequate calcium intake and give them vitamin D,” Dr. Binkley said.

Vitamin D supplementation, in particular, “is an incredibly cost-effective way to intervene,” Dr. McClung agreed. Vitamin D deficiency is very common in the elderly, even in those who still have good mobility. “The older we get, the more dependent we are on higher levels of vitamin D to maintain calcium homeostasis.”

Dr. McClung added that in his own clinic, individuals over the age of 70 are given a 50,000-U dose of vitamin D taken once a month. Study results have suggested that 400 IU of vitamin D per day may not be adequate for many older individuals.

Although a number of drugs have been shown to reduce fracture risk in osteoporotic patients, most of the trials have not involved patients over the age of 80.

Given the lack of supportive data, deciding whether to use bisphosphonates in nursing home residents, however, is tricky.

“My approach, in the absence of data, is to utilize cognition,” Dr. Binkley said. He asks patients if this type of treatment is feasible in their living situation, and he inquires about their desire to take the drug, and how their family feels about the approach. If the responses are favorable, he prescribes a bisphosphonate.

Six Tips to Prevent Fractures

▸ Measure bone density and diagnose osteoporosis in this age group.

▸ Think beyond age: General health and frailty may be better predictors of fracture risk.

▸ Bisphosphonates actually work quickly, and patients will see a benefit.

▸ Anticipate vitamin D deficiencies: High doses are acceptable in this population.

▸ Age is not a barrier to drug response.

▸ Drugs are not the only interventions: Exercise, tools for daily living, and training to prevent falls are effective as well.

Sources: Dr. Binkley, and Dr. McClung.

Bone density screening was associated with fewer hip fractures compared with usual medical care in a study of more than 3,000 adults aged 65 and older.

“Although some groups recommend screening, no study had proved that screening prevents fractures. Our study provides new evidence for the effectiveness of osteoporosis screening,” lead researcher Lisa M. Kern, M.D., of Cornell University, New York, said in a statement.

“We believe that our study is the first to measure and find a direct link between screening for osteoporosis and fewer incident hip fractures,” the researchers said.

But because the study was not randomized, “the observed relationship between screening and hip fracture could be diminished by a small unmeasured confounder,” the investigators noted (Ann. Intern. Med. 2005;142:173-81).

The study included 3,107 participants in the larger Cardiovascular Health Study (CHS). Participants were assigned to a study arm based on the state where they resided.

In one arm, 1,422 participants from California and Pennsylvania were offered osteoporosis screening using dual-energy x-ray absorptiometry (DXA) at the hip. Both the participants and their primary care providers were given a graph showing the results of their bone scan in relation to the normal range of bone mineral density (BMD). The graph did not label the participants as normal, osteopenic, or osteoporotic and did not recommend any particular intervention.

In the other arm, 1,685 participants in Maryland and North Carolina received usual medical care.

The participants were followed for 6 years from the time of their BMD scan, or if they did not receive a scan, from the date of their annual appointment as a CHS participant.

They were observed until one of the following events occurred: a hip fracture, death, loss to follow-up, or end of the surveillance period.

Participants also were analyzed for 31 variables including demographic characteristics, medical histories, medications, and physical examination findings.

Compared with usual care, osteoporosis screening was associated with a statistically significant reduction in the risk of hip fracture. The incidence of fractures per 1,000 person-years was 4.8 in the screened group (total 33) and 8.2 in the usual care group (total 69), linking screening to a 36% reduction in hip fractures.

The largest benefit for screening was in participants aged 85 years and older. “If this result is replicated in other studies, it suggests that guidelines should not set an upper age limit for osteoporosis screening among ambulatory adults,” the researchers wrote.

While acknowledging that the mechanism of the association between screening and a reduction in fractures is unclear, the authors offered several possible explanations.

They found limited evidence that screening may have led to interventions for low bone density.

A total of 33% of participants who were offered screening had a BMD below the age-matched mean, and these participants were more likely to start using calcium or bisphosphonates in the year after screening, compared with those participants whose bone densities were above average.

More screened than nonscreened participants began using multivitamins, Dr. Kern said.

In addition, a smaller percentage of the screened group had falls in the year after screening, compared with the nonscreened group (16% vs. 20%, respectively), although no information on fall prevention was collected.

“There were some other differences between the groups besides screening that could partially explain the difference in hip fractures,” Dr. Kern said.

Bone density screening was associated with fewer hip fractures compared with usual medical care in a study of more than 3,000 adults aged 65 and older.

“Although some groups recommend screening, no study had proved that screening prevents fractures. Our study provides new evidence for the effectiveness of osteoporosis screening,” lead researcher Lisa M. Kern, M.D., of Cornell University, New York, said in a statement.

“We believe that our study is the first to measure and find a direct link between screening for osteoporosis and fewer incident hip fractures,” the researchers said.

But because the study was not randomized, “the observed relationship between screening and hip fracture could be diminished by a small unmeasured confounder,” the investigators noted (Ann. Intern. Med. 2005;142:173-81).

The study included 3,107 participants in the larger Cardiovascular Health Study (CHS). Participants were assigned to a study arm based on the state where they resided.

In one arm, 1,422 participants from California and Pennsylvania were offered osteoporosis screening using dual-energy x-ray absorptiometry (DXA) at the hip. Both the participants and their primary care providers were given a graph showing the results of their bone scan in relation to the normal range of bone mineral density (BMD). The graph did not label the participants as normal, osteopenic, or osteoporotic and did not recommend any particular intervention.

In the other arm, 1,685 participants in Maryland and North Carolina received usual medical care.

The participants were followed for 6 years from the time of their BMD scan, or if they did not receive a scan, from the date of their annual appointment as a CHS participant.

They were observed until one of the following events occurred: a hip fracture, death, loss to follow-up, or end of the surveillance period.

Participants also were analyzed for 31 variables including demographic characteristics, medical histories, medications, and physical examination findings.

Compared with usual care, osteoporosis screening was associated with a statistically significant reduction in the risk of hip fracture. The incidence of fractures per 1,000 person-years was 4.8 in the screened group (total 33) and 8.2 in the usual care group (total 69), linking screening to a 36% reduction in hip fractures.

The largest benefit for screening was in participants aged 85 years and older. “If this result is replicated in other studies, it suggests that guidelines should not set an upper age limit for osteoporosis screening among ambulatory adults,” the researchers wrote.

While acknowledging that the mechanism of the association between screening and a reduction in fractures is unclear, the authors offered several possible explanations.

They found limited evidence that screening may have led to interventions for low bone density.

A total of 33% of participants who were offered screening had a BMD below the age-matched mean, and these participants were more likely to start using calcium or bisphosphonates in the year after screening, compared with those participants whose bone densities were above average.

More screened than nonscreened participants began using multivitamins, Dr. Kern said.

In addition, a smaller percentage of the screened group had falls in the year after screening, compared with the nonscreened group (16% vs. 20%, respectively), although no information on fall prevention was collected.

“There were some other differences between the groups besides screening that could partially explain the difference in hip fractures,” Dr. Kern said.

Bone density screening was associated with fewer hip fractures compared with usual medical care in a study of more than 3,000 adults aged 65 and older.

“Although some groups recommend screening, no study had proved that screening prevents fractures. Our study provides new evidence for the effectiveness of osteoporosis screening,” lead researcher Lisa M. Kern, M.D., of Cornell University, New York, said in a statement.

“We believe that our study is the first to measure and find a direct link between screening for osteoporosis and fewer incident hip fractures,” the researchers said.

But because the study was not randomized, “the observed relationship between screening and hip fracture could be diminished by a small unmeasured confounder,” the investigators noted (Ann. Intern. Med. 2005;142:173-81).

The study included 3,107 participants in the larger Cardiovascular Health Study (CHS). Participants were assigned to a study arm based on the state where they resided.

In one arm, 1,422 participants from California and Pennsylvania were offered osteoporosis screening using dual-energy x-ray absorptiometry (DXA) at the hip. Both the participants and their primary care providers were given a graph showing the results of their bone scan in relation to the normal range of bone mineral density (BMD). The graph did not label the participants as normal, osteopenic, or osteoporotic and did not recommend any particular intervention.

In the other arm, 1,685 participants in Maryland and North Carolina received usual medical care.

The participants were followed for 6 years from the time of their BMD scan, or if they did not receive a scan, from the date of their annual appointment as a CHS participant.

They were observed until one of the following events occurred: a hip fracture, death, loss to follow-up, or end of the surveillance period.

Participants also were analyzed for 31 variables including demographic characteristics, medical histories, medications, and physical examination findings.

Compared with usual care, osteoporosis screening was associated with a statistically significant reduction in the risk of hip fracture. The incidence of fractures per 1,000 person-years was 4.8 in the screened group (total 33) and 8.2 in the usual care group (total 69), linking screening to a 36% reduction in hip fractures.

The largest benefit for screening was in participants aged 85 years and older. “If this result is replicated in other studies, it suggests that guidelines should not set an upper age limit for osteoporosis screening among ambulatory adults,” the researchers wrote.

While acknowledging that the mechanism of the association between screening and a reduction in fractures is unclear, the authors offered several possible explanations.

They found limited evidence that screening may have led to interventions for low bone density.

A total of 33% of participants who were offered screening had a BMD below the age-matched mean, and these participants were more likely to start using calcium or bisphosphonates in the year after screening, compared with those participants whose bone densities were above average.

More screened than nonscreened participants began using multivitamins, Dr. Kern said.

In addition, a smaller percentage of the screened group had falls in the year after screening, compared with the nonscreened group (16% vs. 20%, respectively), although no information on fall prevention was collected.

“There were some other differences between the groups besides screening that could partially explain the difference in hip fractures,” Dr. Kern said.

COLORADO SPRINGS — The anabolic bone-forming agent teriparatide (Forteo) is winning anecdotal raves for augmentation of fracture healing in both nonosteoporotic and osteoporotic patients.

“This is a very exciting metabolic therapy. My experience so far really does show that it works,” Thomas P. Knecht, M.D., declared at a meeting of the Colorado chapter of the American College of Physicians.

Acceleration of fracture healing is an off-label use of teriparatide, the N-terminal 34-amino-acid chain of human parathyroid hormone. Teriparatide's approved indications are for treatment of postmenopausal osteoporotic women at high fracture risk, and for increasing bone mass in osteoporotic men at elevated fracture risk.

The evidence for augmentation of fracture healing comes from multiple favorable animal studies as well as anecdotal clinical experiences that are consistent with the animal findings, explained Dr. Knecht, an endocrinologist at the University of Utah, Salt Lake City.

He offered two illustrative cases from his own practice, both involving middle-aged recreational athletes eager for a rapid return to sports.

One was a 48-year-old man with type 1 diabetes and normal bone mineral density test scores who became severely hypoglycemic, lost consciousness, and fell, fracturing his right tibia and fibula in multiple places. Surgeons placed a metal rod knee to ankle.

The bone pain quickly became nonlimiting after Dr. Knecht placed him on teriparatide.

He began long-distance running 3 months post surgery, and downhill skiing a week after that.

“My assessment of this patient's response was that placebo can't do that. Nobody placebos their way through a fracture like that one. So you have to say the healing was dramatic and the pain response was dramatic,” he observed.

Another patient was a 38-year-old woman, also with normal T scores on dual x-ray absorptiometry bone mineral density testing, who fell while training for a half-marathon and fractured her great toe. The break involved the metatarsophalangeal joint.

Yet her fracture pain resolved after a single week on teriparatide. Six weeks later she completed her half-marathon.

While both these patients had good bone mineral density, Dr. Knecht said he has regularly seen the same sort of results—“not only a dramatic pain response, but an absolutely striking metabolic response”—in patients he has placed on teriparatide to augment healing of osteoporotic fractures.

While daily subcutaneous injections of teriparatide are typically given for 2 years in patients taking the agent for the approved indications, 6 months of therapy appears to be “more than adequate” for fracture healing per se because the healing occurs so quickly, he continued.

This is a high-cost drug. Its off-label use to accelerate fracture healing requires a highly motivated patient willing to take on a substantial out-of-pocket expense, according to Dr. Knecht, who is on the speakers' bureau for Eli Lilly & Co., which markets teriparatide.

COLORADO SPRINGS — The anabolic bone-forming agent teriparatide (Forteo) is winning anecdotal raves for augmentation of fracture healing in both nonosteoporotic and osteoporotic patients.

“This is a very exciting metabolic therapy. My experience so far really does show that it works,” Thomas P. Knecht, M.D., declared at a meeting of the Colorado chapter of the American College of Physicians.

Acceleration of fracture healing is an off-label use of teriparatide, the N-terminal 34-amino-acid chain of human parathyroid hormone. Teriparatide's approved indications are for treatment of postmenopausal osteoporotic women at high fracture risk, and for increasing bone mass in osteoporotic men at elevated fracture risk.

The evidence for augmentation of fracture healing comes from multiple favorable animal studies as well as anecdotal clinical experiences that are consistent with the animal findings, explained Dr. Knecht, an endocrinologist at the University of Utah, Salt Lake City.

He offered two illustrative cases from his own practice, both involving middle-aged recreational athletes eager for a rapid return to sports.

One was a 48-year-old man with type 1 diabetes and normal bone mineral density test scores who became severely hypoglycemic, lost consciousness, and fell, fracturing his right tibia and fibula in multiple places. Surgeons placed a metal rod knee to ankle.

The bone pain quickly became nonlimiting after Dr. Knecht placed him on teriparatide.

He began long-distance running 3 months post surgery, and downhill skiing a week after that.

“My assessment of this patient's response was that placebo can't do that. Nobody placebos their way through a fracture like that one. So you have to say the healing was dramatic and the pain response was dramatic,” he observed.

Another patient was a 38-year-old woman, also with normal T scores on dual x-ray absorptiometry bone mineral density testing, who fell while training for a half-marathon and fractured her great toe. The break involved the metatarsophalangeal joint.

Yet her fracture pain resolved after a single week on teriparatide. Six weeks later she completed her half-marathon.

While both these patients had good bone mineral density, Dr. Knecht said he has regularly seen the same sort of results—“not only a dramatic pain response, but an absolutely striking metabolic response”—in patients he has placed on teriparatide to augment healing of osteoporotic fractures.

While daily subcutaneous injections of teriparatide are typically given for 2 years in patients taking the agent for the approved indications, 6 months of therapy appears to be “more than adequate” for fracture healing per se because the healing occurs so quickly, he continued.

This is a high-cost drug. Its off-label use to accelerate fracture healing requires a highly motivated patient willing to take on a substantial out-of-pocket expense, according to Dr. Knecht, who is on the speakers' bureau for Eli Lilly & Co., which markets teriparatide.

COLORADO SPRINGS — The anabolic bone-forming agent teriparatide (Forteo) is winning anecdotal raves for augmentation of fracture healing in both nonosteoporotic and osteoporotic patients.

“This is a very exciting metabolic therapy. My experience so far really does show that it works,” Thomas P. Knecht, M.D., declared at a meeting of the Colorado chapter of the American College of Physicians.

Acceleration of fracture healing is an off-label use of teriparatide, the N-terminal 34-amino-acid chain of human parathyroid hormone. Teriparatide's approved indications are for treatment of postmenopausal osteoporotic women at high fracture risk, and for increasing bone mass in osteoporotic men at elevated fracture risk.

The evidence for augmentation of fracture healing comes from multiple favorable animal studies as well as anecdotal clinical experiences that are consistent with the animal findings, explained Dr. Knecht, an endocrinologist at the University of Utah, Salt Lake City.

He offered two illustrative cases from his own practice, both involving middle-aged recreational athletes eager for a rapid return to sports.

One was a 48-year-old man with type 1 diabetes and normal bone mineral density test scores who became severely hypoglycemic, lost consciousness, and fell, fracturing his right tibia and fibula in multiple places. Surgeons placed a metal rod knee to ankle.

The bone pain quickly became nonlimiting after Dr. Knecht placed him on teriparatide.

He began long-distance running 3 months post surgery, and downhill skiing a week after that.

“My assessment of this patient's response was that placebo can't do that. Nobody placebos their way through a fracture like that one. So you have to say the healing was dramatic and the pain response was dramatic,” he observed.

Another patient was a 38-year-old woman, also with normal T scores on dual x-ray absorptiometry bone mineral density testing, who fell while training for a half-marathon and fractured her great toe. The break involved the metatarsophalangeal joint.

Yet her fracture pain resolved after a single week on teriparatide. Six weeks later she completed her half-marathon.

While both these patients had good bone mineral density, Dr. Knecht said he has regularly seen the same sort of results—“not only a dramatic pain response, but an absolutely striking metabolic response”—in patients he has placed on teriparatide to augment healing of osteoporotic fractures.

While daily subcutaneous injections of teriparatide are typically given for 2 years in patients taking the agent for the approved indications, 6 months of therapy appears to be “more than adequate” for fracture healing per se because the healing occurs so quickly, he continued.

This is a high-cost drug. Its off-label use to accelerate fracture healing requires a highly motivated patient willing to take on a substantial out-of-pocket expense, according to Dr. Knecht, who is on the speakers' bureau for Eli Lilly & Co., which markets teriparatide.

Adolescent women who use the injectable contraceptive depot medroxyprogesterone acetate lose bone mineral density each year they are on the drug but appear to rapidly recover that loss when the drug is withdrawn, results of a prospective study suggest.

“The potential loss of bone density is one consideration of the many that go into a women's choice of contraceptive method,” said Delia Scholes, Ph.D., of the Center for Health Studies, Seattle, and her associates.

Dr. Scholes and her associates prospectively examined BMD in a cohort of 170 females aged 14-18. A total of 80 participants were using DMPA, and 90 were not. The DMPA-exposed teens were significantly more likely to be current smokers, to have been pregnant, have reached earlier menarche, and have a higher body mass index and body fat percentage (Arch. Pediatr. Adolesc. Med. 2005;159:139-44).

During the study, 61 of the DMPA users discontinued the contraceptive, affording the opportunity to observe any subsequent changes in BMD.

The DMPA-exposed subjects were receiving the standard dose of 150 mg every 3 months. About 30% of them had received only 1 injection, 31% had received 2 or 3 injections, 21% had received 4-7 injections, and 18% had received at least 18 injections. In the comparison group, 19% were using oral contraceptives at baseline.

BMD was measured at the hip, spine, and whole body every 6 months for 24-36 months. After adjustment the DMPA users had lost significantly more BMD at the hip (-1.81% vs. -0.19%) and spine (-0.97% vs. 1.32%), compared with nonusers. Both groups gained BMD when the whole body was measured, but the DMPA users gained significantly less than the nonusers (0.73% vs 0.88%). New users lost bone faster than continuous users. After 24 months, new users showed a -6.09% change at the hip, compared with -2.05% in continuous users and -0.92% in nonusers.

Among the 61 subjects who discontinued DMPA during the study, BMD increased. Their annualized adjusted mean change in BMD was 1.34% for hip, 2.86% for spine, and 3.56% for the whole body. There was no significant difference in BMD between nonusers and those who discontinued DMPA 18 months earlier.

The injection is highly effective in preventing pregnancy and may help reduce compliance problems, the researchers said.

In 2004, the Food and Drug Administration issued a black box warning for DMPA stating that prolonged use of the drug could result in significant loss of bone density, that the loss is greater the longer the drug is administered, and that bone density loss may not be completely reversible after discontinuing the drug.

Adolescent women who use the injectable contraceptive depot medroxyprogesterone acetate lose bone mineral density each year they are on the drug but appear to rapidly recover that loss when the drug is withdrawn, results of a prospective study suggest.

“The potential loss of bone density is one consideration of the many that go into a women's choice of contraceptive method,” said Delia Scholes, Ph.D., of the Center for Health Studies, Seattle, and her associates.

Dr. Scholes and her associates prospectively examined BMD in a cohort of 170 females aged 14-18. A total of 80 participants were using DMPA, and 90 were not. The DMPA-exposed teens were significantly more likely to be current smokers, to have been pregnant, have reached earlier menarche, and have a higher body mass index and body fat percentage (Arch. Pediatr. Adolesc. Med. 2005;159:139-44).

During the study, 61 of the DMPA users discontinued the contraceptive, affording the opportunity to observe any subsequent changes in BMD.

The DMPA-exposed subjects were receiving the standard dose of 150 mg every 3 months. About 30% of them had received only 1 injection, 31% had received 2 or 3 injections, 21% had received 4-7 injections, and 18% had received at least 18 injections. In the comparison group, 19% were using oral contraceptives at baseline.

BMD was measured at the hip, spine, and whole body every 6 months for 24-36 months. After adjustment the DMPA users had lost significantly more BMD at the hip (-1.81% vs. -0.19%) and spine (-0.97% vs. 1.32%), compared with nonusers. Both groups gained BMD when the whole body was measured, but the DMPA users gained significantly less than the nonusers (0.73% vs 0.88%). New users lost bone faster than continuous users. After 24 months, new users showed a -6.09% change at the hip, compared with -2.05% in continuous users and -0.92% in nonusers.

Among the 61 subjects who discontinued DMPA during the study, BMD increased. Their annualized adjusted mean change in BMD was 1.34% for hip, 2.86% for spine, and 3.56% for the whole body. There was no significant difference in BMD between nonusers and those who discontinued DMPA 18 months earlier.

The injection is highly effective in preventing pregnancy and may help reduce compliance problems, the researchers said.

In 2004, the Food and Drug Administration issued a black box warning for DMPA stating that prolonged use of the drug could result in significant loss of bone density, that the loss is greater the longer the drug is administered, and that bone density loss may not be completely reversible after discontinuing the drug.

Adolescent women who use the injectable contraceptive depot medroxyprogesterone acetate lose bone mineral density each year they are on the drug but appear to rapidly recover that loss when the drug is withdrawn, results of a prospective study suggest.

“The potential loss of bone density is one consideration of the many that go into a women's choice of contraceptive method,” said Delia Scholes, Ph.D., of the Center for Health Studies, Seattle, and her associates.

Dr. Scholes and her associates prospectively examined BMD in a cohort of 170 females aged 14-18. A total of 80 participants were using DMPA, and 90 were not. The DMPA-exposed teens were significantly more likely to be current smokers, to have been pregnant, have reached earlier menarche, and have a higher body mass index and body fat percentage (Arch. Pediatr. Adolesc. Med. 2005;159:139-44).

During the study, 61 of the DMPA users discontinued the contraceptive, affording the opportunity to observe any subsequent changes in BMD.

The DMPA-exposed subjects were receiving the standard dose of 150 mg every 3 months. About 30% of them had received only 1 injection, 31% had received 2 or 3 injections, 21% had received 4-7 injections, and 18% had received at least 18 injections. In the comparison group, 19% were using oral contraceptives at baseline.

BMD was measured at the hip, spine, and whole body every 6 months for 24-36 months. After adjustment the DMPA users had lost significantly more BMD at the hip (-1.81% vs. -0.19%) and spine (-0.97% vs. 1.32%), compared with nonusers. Both groups gained BMD when the whole body was measured, but the DMPA users gained significantly less than the nonusers (0.73% vs 0.88%). New users lost bone faster than continuous users. After 24 months, new users showed a -6.09% change at the hip, compared with -2.05% in continuous users and -0.92% in nonusers.

Among the 61 subjects who discontinued DMPA during the study, BMD increased. Their annualized adjusted mean change in BMD was 1.34% for hip, 2.86% for spine, and 3.56% for the whole body. There was no significant difference in BMD between nonusers and those who discontinued DMPA 18 months earlier.

The injection is highly effective in preventing pregnancy and may help reduce compliance problems, the researchers said.

In 2004, the Food and Drug Administration issued a black box warning for DMPA stating that prolonged use of the drug could result in significant loss of bone density, that the loss is greater the longer the drug is administered, and that bone density loss may not be completely reversible after discontinuing the drug.