Older men with fractures and bone biopsy after teriparatide
The near absence of osteoporosis treatment in older men with fractures. See Osteoporos Int. 2005 Jun 1;[Epub ahead of print], Feldstein AC and others, PMID: 15928798. This was a retrospective study in the U.S. of 1,171 men 65 or older with new fractures associated with osteoporosis. The authors examined whether participants received pharmacologic treatment for osteoporosis within six months of having a fracture. The results showed that only 3.3% had a diagnosis of osteoporosis after a fracture. Only 7.1% of the study population and 16% of those with a hip or vertebral fracture received a medication for osteoporosis following the index fracture. Only 13 participants, 1.1%, received a bone density test. Editor's comments: These results are almost unbelievable with only one possible explanation: The study was done from 1998 to 2001. One can only hope that there is more awareness of men's osteoporosis issues since 2001 and that more older men are now getting proper diagnosis and therapy. It is safer, however, not to make assumptions. If you or some older man that you know has a low-impact fracture, assume that osteoporosis is the cause until proven otherwise. That means after a low-impact fracture an appointment with a medical specialist in osteoporosis is required to have proper diagnostic testing done, especially including bone density testing.
Bone mineral and collagen quality in iliac crest biopsies of patients given teriparatide: New results from the fracture prevention trial. See J Clinc Endocrinol Metab. 2005 May 24 [Epub ahead of print], Paschalis EP and others. PMID: 15914535. When considering fracture risk there are two important issues to consider: Bone density and bone quality. We have no noninvasive tests for bone quality, instead a bone biopsy is required. This study looked at iliac crest biopsies after postmenopausal women received either 20 or 40 microg of teriparatide (Forteo) for either 12 months or 19-24 months of treatment. The important result of this study was that, "These findings indicate that the bone-forming effect of teriparatide results in bone with a molecular profile reminiscent of younger bone." Editor's comment: This is an interesting finding since teriparatide works by stimulating new bone formation. It is reassuring to know that this new bone is high quality and microscopically similar to young bone. The bisphosphonates (such as Fosamax or Actonel), however, work by blocking bone breakdown. The bisphosphonates thus allow bone to form, but there is some concern that long term there is inadequate remodeling which could lead to a lower quality of bone mineral. Of course, teriparatide can only be used for 1-2 years and then the individual must get another pharmacological osteoporosis therapy, such as the bisphosphonates. So it is unknown if the early high quality bone formed with teriparatide will give long term improvements in bone quality once it is followed up by another osteoporosis medication. Here is another recent paper on teriparatide with some interesting information that adds to that in the Paschalis and others study: See Endocr Rev. 2005 Mar 15; [Epub ahead of print], Hodsman AB and others, PMID: 15769903. Of particular interest is the authors' comments regarding who should have teriparatide therapy: "Teriparatide should also be considered for the management of individuals at particularly high risk for fractures, including subjects who are younger than age 65 and who have particularly low BMD measurements (T-scores </=3.5)."