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xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses advances in osteoporosis in postmenopausal women, in glucocorticoid-induced osteoporosis, and secondary to rheumatic diseases.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EBone Density \u0026amp; Structure Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMetabolic Bone Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EMetabolic Bone Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EBone Density \u0026amp; Structure Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERheumatology\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EWillem F. Lems, MD, VU University Medical Center and Reade, Amsterdam, The Netherlands, discussed advances in osteoporosis in postmenopausal (PM) women, in glucocorticoid-induced osteoporosis (GIOP), and secondary to rheumatic diseases (RDs).\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPOSTMENOPAUSAL OSTEOPOROSIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EThe bisphosphonates (BSP) alendronate, risedronate (RISE), and zoledronic acid, and the monoclonal antibody denosumab (DEN), are the only agents shown to reduce vertebral and nonvertebral fractures. It is not known if patients with PM osteoporosis who have received 5 years of BSP therapy should continue or stop treatment; data for the long-term effects of BSP are lacking.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EAtypical femoral fracture (AFF) is a serious adverse event (AE) related to the duration of BSP therapy, and it is also associated with DEN. AFFs are stress fractures in the femoral shaft (or occasionally another location), are usually preceded by prodromal pain, and heal poorly [Shane E et al. \u003Cem\u003EJ Bone Miner Res\u003C\/em\u003E 2014]; histology shows bone remodeling in the absence of healing. Prof. Lems said that the benefit of fracture reduction with BSP and DEN nevertheless surpasses the risks of AEs like AFF and osteonecrosis of the jaw (ONJ). In a study titled the Effect of Teriparatide on Fracture Healing in Patients With Incomplete Atypical Femur Fractures [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01896011\u0026amp;atom=%2Fspmdc%2F14%2F17%2F25.atom\u0022\u003ENCT01896011\u003C\/a\u003E], which was conducted with PM women with bilateral (n=17) or unilateral (n=5) AFF who had used BSP for a mean of 12 years, treatment with teriparatide (TERI; recombinant parathyroid hormone) for a mean of 18.8 months was associated with healed (n=2), healing (n=5), or stable (n=12) AFF.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EDEN treatment resulted in a continued increase in bone mineral density (BMD) and a stable, low incidence of vertebral and nonvertebral fractures; this was seen at \u22658 years (5 years in patients who crossed over from placebo to DEN) of follow-up in the extension of FREEDOM, a Study to Evaluate Denosumab in the Treatment of Postmenopausal Osteoporosis [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00089791\u0026amp;atom=%2Fspmdc%2F14%2F17%2F25.atom\u0022\u003ENCT00089791\u003C\/a\u003E].\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003ENew anti-osteoporotic agents are under development. In a Phase 2 trial comparing romosozumab (ROMO), a monoclonal antibody against sclerostin, with placebo, alendronate, or TERI in PM women with low BMD [McClung MR et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2014], the highest dose of ROMO increased BMD in the lumbar spine, hip, and femoral neck to a greater extent than the other treatments. Odanacatib, a cathepsin K inhibitor, increased lumbar spine and femoral neck BMD and reduced a marker of bone resorption in PM women with low BMD [Brixen K et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2013]. Two years of therapy with the combination of DEN plus TERI in PM women with osteoporosis showed increased BMD in the lumbar spine, femoral neck, and total hip compared with either agent alone in the DATA extension study [Leder BZ et al. \u003Cem\u003EJ Clin Endocrinol Metab\u003C\/em\u003E 2014]. These agents will be studied further for efficacy and safety.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EA case\u2013control study showed that after 5 years of follow-up, femoral strength correlated with the femoral neck area BMD T-score, and it defined a threshold for hip fracture \u223cT\u2264\u20131.3 [Kopperdahl DL et al. \u003Cem\u003EJ Bone Miner Res\u003C\/em\u003E 2014]. Prof. Lems said that treatment increasing BMD to this level in patients with osteoporosis might indicate treatment success.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EGenetic studies of osteoporosis risk are ongoing. For example, some mutations in the gene for plastin 3 (PLS3), an actin-bundling protein, are associated with X-linked osteoporosis with fractures [van Dijk FS et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2013].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EOSTEOPOROSIS IN PATIENTS TREATED WITH GLUCOCORTICOIDS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EThe fracture rate in patients treated with high-dose glucocorticoids (GCs) is high and dose related; GCs increase bone resorption and decrease bone formation. In patients with RDs, the disease itself as well as the GCs used in treatment may have a negative effect on BMD. Treatment with lower dose GCs and with BSPs might prevent osteoporosis, but this depends on achieving effective control of the RD with lower dose GCs. A framework for the development of guidelines for the management of GIOP is shown in \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E [Lekamwasan S et al. \u003Cem\u003EOsteoporos Int\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/17\/25\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Guidelines for Glucocorticoid-Induced Osteoporosis\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-74483269\u0022 data-figure-caption=\u0022Guidelines for Glucocorticoid-Induced Osteoporosis\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/17\/25\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/17\/25\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/17\/25\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14605\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-10\u0022 class=\u0022first-child\u0022\u003EGuidelines for Glucocorticoid-Induced Osteoporosis\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EBMD=bone mineral density.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003E\n               \u003Csup\u003Ea\u003C\/sup\u003E Threshold will vary according to country.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EReproduced from Lekamwasan S et al. A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis. \u003Cem\u003EOsteoporos Int\u003C\/em\u003E 2012;23:2257\u20132276. With permission from Springer Verlag.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EEuroGIOPS is a study of men with GIOP treated with TERI or RISE [Gluer CC et al. \u003Cem\u003EJ Bone Miner Res\u003C\/em\u003E 2013], and it is one of the few studies of osteoporosis in men. At 18 months, RESI significantly increased lumbar spine trabecular BMD and vertebral strength compared with RISE. Changes in bone strength correlated positively with bone turnover markers in the group treated with TERI [Farahmand P et al. \u003Cem\u003EOsteoporos Int\u003C\/em\u003E 2013].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EOSTEOPOROSIS SECONDARY TO RHEUMATIC DISEASES\u003C\/h2\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EAs mentioned, osteoporosis in patients with RD may be secondary to their disease itself. In patients whose disease is not adequately treated, inflammatory molecules (eg, tumor necrosis factors and interleukins) may affect bone remodeling. Upregulated osteoclasts may increase bone resorption, and downregulated osteoblasts may decrease bone formation. Risk factors for generalized bone loss and fractures in patients with rheumatoid arthritis (RA) are shown in \u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E [Vis M et al. \u003Cem\u003EOsteoporos Int\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/17\/25\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Risk Factors of Generalized Bone Loss and Fractures in Rheumatoid Arthritis\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-74483269\u0022 data-figure-caption=\u0022Risk Factors of Generalized Bone Loss and Fractures in Rheumatoid Arthritis\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/17\/25\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/17\/25\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/17\/25\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14607\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003ERisk Factors of Generalized Bone Loss and Fractures in Rheumatoid Arthritis\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EBMI=body mass index; RA=rheumatoid arthritis.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-5\u0022\u003EReproduced from Vis M et al. Can bone loss in rheumatoid arthritis be prevented? \u003Cem\u003EOsteoporos Int\u003C\/em\u003E 2013;24:2541\u20132553. With permission from Springer Verlag.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EIf inflammation does play a role in osteoporosis in RA, then agents that decrease inflammation should improve BMD. In patients with RA treated with adalimumab, those whose disease responded well had an increased BMD, whereas those whose disease did not respond or responded only moderately lost BMD in both the hip and spine. [Krieckaert CL et al. \u003Cem\u003ERheumatology (Oxford)\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003ENew methods of bone imaging with higher resolution, low-radiation dosage, and decreased acquisition time, such as high-resolution peripheral quantitative computed tomography (HR-pQCT), should improve the ability to visualize bone and joint microarchitecture at baseline and during treatment and fracture healing. The equipment to perform HR-pQCT currently is very expensive, however, and it is being used in the research setting.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EDecreased BMD is also seen in patients with RA who have anticitrullinated protein antibodies [Kleyer A et al. \u003Cem\u003EAnn Rheum Dis\u003C\/em\u003E 2014]. The presence of these antibodies, and the cortical bone changes associated with them, can occur before RA symptoms appear, supporting the role of RA in causing osteoporosis.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EBPs and DEN are effective agents for treating osteoporosis, although the optimal duration of therapy is unknown. Newer agents with different mechanisms of action are being developed. In addition to treating osteoporosis after it develops, adequate treatment of the inflammation associated with RA helps to reduce disease-associated bone loss.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/17\/25.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzp3uq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzp3uq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}