It is a typical and frequent clinical picture in children. You are describing a contagious impetigo. There is not much dispute. The most frequent causative agent in the bullous form is S. aureus phage II.

An 8-year-old patient presenting with superficial pustular lesions, erosions and yellowish crusts around the mouth for the last 3 days:

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY

Infantile generalized pustular psoriasis: successful disease control with intermittent etretinate.

Infantile generalized pustular psoriasis is a rare form of psoriasis and the best treatment is controversial. We experienced a 2-year-old female with erythema on her neck and axilla starting at 3 months of age. She presented with recurrent annular and geographic scaly erythema with a few pustules on the neck, precordium and axilla, but no fever. The histopathology revealed subcorneal neutrophilic infiltration and microabscesses without Kogoj's spongiform pustules. The initial diagnosis was subcorneal pustular dermatosis. However, she developed widespread geographic erythema and numerous pustules over her entire body with a fever when she got a cold. A second skin biopsy revealed monolocular pustules and Kogoj's spongiform pustules in the subcorneal layer. Etretinate was administrated after a diagnosis of pustular psoriasis was made and her condition improved gradually. The choice of treatment depends on patient age, general condition and the disease severity.

Familial juvenile generalized pustular psoriasis: response to methotrexate.

Two siblings with generalized pustular psoriasis were admitted to the hospital. Case 1: A 7-year-old girl presented with recurrent episodes of multiple pinhead-sized pustules all over her body since the age of 3. The current episode began a week prior to the onset of the lesions. On cutaneous examination, she had generalized erythema topped with tiny pustules, scales, and crusting (Figure 1A). A Gram stain performed from the pustule and cultures taken from the pus and blood were sterile. Histopathology of the pustule was suggestive of pustular psoriasis (Figure 2). Hemoglobin was 8.8 g%. Other hematologic, microbiologic, and radiologic investigations were normal. Treatment was started with methotrexate, to which she responded dramatically with reduction in appearance of new lesions, erythema, and scaling. After 4 weeks of treatment, there was almost 90% clearance of skin lesions. Case 2: A 3-year-old boy, brother of the patient in case 1, presented with similar complaints for the past week. The episode was preceded by high-grade fever. He had generalized erythema, scaling, and edema and multiple pinhead-sized pustules, some of which were arranged in an annular configuration (Figure 1B). All investigations, as in case 1, were normal except for hypocalcemia (Ca2+ = 8.8 g%) and generalized rarefaction on x-rays of both the ankle joints. Treatment was started with prednisolone (because of poor general condition) and methotrexate. Following therapy, significant improvement was evident with reduction in erythema and cessation of appearance of new pustules. The dose of prednisolone was gradually tapered after 3 weeks and then stopped.

Acute generalized exanthematous pustulosis with erythema multiforme-like lesions.

Acute generalized exanthematous pustulosis (AGEP) resembles generalized pustular psoriasis, but may manifest targetoid lesions, purpura, and blisters in addition to pustules. We describe a case of AGEP with erythema multiforme (EM)-like features in a 35-year-old woman who presented with acute onset of high fever and a strikingly polymorphic eruption consisting of numerous tiny pustules on erythematous bases, marked facial edema, oral and genital erosions, targetoid vesicular and purpuric lesions, pustules in string-of-pearl configuration and ring-like vesicles. The histology revealed, in addition to subcorneal pustules, vacuolar interface dermatitis with involvement of eccrine glands, and microabscesses in pilosebaceous structures. Systemic corticorsteroid and antibiotics were initiated, resulting in rapid resolution without recurrence. Recognition of EM-like lesions on a background of generalized pustular eruption could facilitate the diagnosis of AGEP and the institution of appropriate treatment.

Generalized pustular psoriasis

Infantile and juvenile GPP is a rare disease in general, but even more so in children. In 2010, an article was published in Pediatric Dermatology by the Department of Dermatology, University of São Paulo. The report acknowledged that psoriasis is a relatively common skin condition in children, but "the pustular variant is rare." Out of 1,262 cases of psoriasis in children, a "0.6% rate of pustular variants" was found. When GPP does occur in children, it usually appears during the first year of life. Khan et al. reported that in GPP patients ten or younger, less than 12% of cases are preceded by ordinary psoriasis. This differs greatly from GPP cases in adults, where 85% of GPP is preceded by typical psoriatic lesions.

Recurrent impetigo herpetiformis in a pregnant adolescent: case report.

Impetigo Herpetiformis is a rare pustular dermatosis that typically occurs in pregnant women with unknown etiology. A 17 year old patient who developed Impetigo Herpetiformis for the second time in the 27th week of her 2nd pregnancy is presented. The patient improved with corticosteroids treatment but the lesions did not clear completely and had flare ups during stressful periods which brings us to conclusion that Impetigo Herpetiformis at least has a common pathway with Generalized Pustular Psoriasis in the pathogenesis as stress provoked exacerbations.

Ritodrine-induced pustular eruptions distinctly resembling impetigo herpetiformis.

A 27-year-old nulligravida woman without a history of dermatosis was hospitalized for threatened preterm labor at 29 weeks' gestation; therefore, continuous infusion of ritodrine hydrochloride was started. At 31 weeks' gestation, erythematous plaques appeared and spread over the body surface; therefore, a topical steroid preparation was applied. At 32 weeks' gestation, the eruptions developed into irregular annular areas of erythema with multiple pustules accompanied by severe itching, and oral prednisolone treatment was started. Bacterial cultures of the pustules were negative, and a crural cutaneous biopsy revealed Kogoj's spongiform pustules. Based on the clinicopathological findings, the most likely diagnosis was impetigo herpetiformis, which causes cutaneous symptoms closely resembling pustular psoriasis in pregnant females without a history of psoriasis. To rule out ritodrine-induced pustular eruptions, the ritodrine infusion was stopped and treatment with an MgSO(4) preparation was started at 33 weeks' 3 days' gestation; however, the uterine contractions could not be suppressed. Because of the patient's highly edematous, severely painful feet, a cesarean section was performed the same day. Within several days of delivery, the eruptions began to resolve, and no recurrence was observed after treatment with oral prednisolone was stopped 31 days after delivery. On the basis of a positive patch test for ritodrine, we diagnosed pustular drug eruptions caused by ritodrine hydrochloride. Although ritodrine-induced pathognomonic cutaneous eruptions are rare, we would like to emphasize that ritodrine can cause drug-induced pustular eruptions distinctly resembling life-threatening impetigo herpetiformis.

Pustular psoriasis

Generalized pustular psoriasis (GPP) is also known as (von Zumbusch) acute generalized pustular psoriasis in acute cases, and as impetigo herpetiformis during pregnancy. GPP is a rare and severe form of psoriasis that may require hospitalization. This form of psoriasis is characterized by an acute onset of numerous pustules on top of tender red skin. This skin eruption is often accompanied by a fever, muscle aches, nausea, and an elevated white blood cell count. Annular pustular psoriasis (APP), a rare form of GPP, is the most common type seen during childhood. APP tends to occur in women more frequently than in men, and is usually less severe than other forms of generalized pustular psoriasis such as impetigo herpetiformis. This form of psoriasis is characterized by ring-shaped plaques with pustules around the edges and yellow crusting. APP most often affects the torso, neck, arms, and legs. Diagnosis

Generalized pustular psoriasis

Case reports Case report 1 Von Zumbusch observed a male patient, who had had classic psoriasis for several years, and who then went through recurrent episodes of bright [erythema] and [edema], which became studded with multiple pustules. Von Zumbusch observed this patient through nine hospital admissions over 10 years. Case report 2 Hazarika gave a report of a 29-year-old woman with no family history of psoriasis, having had a normal first pregnancy, who presented with GPP in the twenty-eighth week of her second pregnancy. Steroid therapy caused a worsening of the symptoms. With cyclosporine the lesions cleared in 10–14 days, but new lesions appeared. The patient gave birth to a healthy baby in the thirty-eighth week of pregnancy. A month and a half after delivery, the woman presented with a psoriatic plaque on her leg.

[Kawasaki's disease with eruptive pustular and guttate psoriasis].

Kawasaki's disease may have numerous atypical forms and these must be recognized in order to avoid delay of treatment. We report a case of psoriasis, first pustular and then guttate, occurring during Kawasaki's disease, and discuss a common pathophysiological mechanism. A 3 year-old boy was seen for a febrile exanthema suggestive of Kawasaki disease (bilateral conjunctivitis, red and fissured lips, palmoplantar erythema, scarlet fever-like rash and perineal desquamation) associated with pustular lesions. A biopsy specimen of a pustular area showed histological features consistent with the diagnosis of pustular psoriasis. No coronary abnormality was found. The child was treated with intravenous immunoglobulins (2 g/kg) and oral aspirin (60 mg/kg/d). All the symptoms disappeared and immediate follow-up was marked by the appearance of guttate psoriasis. Onset of psoriatic lesions during Kawasaki disease has been reported in 12 cases, either in acute phase or in immediate follow-up. Coronary complications have been found in 4 of 5 cases with acute psoriasis, suggesting a severe prognosis for this association. The hypothesis of a common pathophysiological mechanism is discussed with the intervention of a bacterial toxin acting as a superantigen and resulting in an strong activation of T-cells that leads to keratinocyte activation. The psoriatic lesions could hence be considered as a form of Köbner's phenomenon.

Generalized Pustular Psoriasis -- History and Physical

Impetigo herpetiformis represents widespread pustular psoriasis occurring in pregnancy. Onset is usually in the third trimester of pregnancy, but may be earlier, and has been documented in the first month of pregnancy and in the first day of the puerperium. The disease often persists until the child is born and may last after childbirth. It is characterized by salient features of generalized pustular psoriasis, usually starting from flexural surfaces as symmetrical, confluent areas of pustulation. The outbreak of lesions begins in the groin region and other flexures, with small pustules appearing on an inflamed skin. These spread radially, become dry in the center, or form plaques which may become widespread and leave a reddish brown pigmentation as they heal. The tongue, oral cavity, and even the esophagus may be involved, with erosions following pustules.

Generalized pustular psoriasis

Case report 3 An eleven-year-old boy had an eight-year history of recurrent GPP. He suffered from "fever, malaise and pain". He was treated with acitretin, and improvement was seen in five weeks. Case report 4 In 1991, a case was reported of a man having plaque psoriasis and treating it with UV radiation at a tanning salon. After receiving a partial thickness burn from overexposure, he presented with annular pustular psoriasis, which cleared after 21 days, only to reoccur every 3 to 6 weeks for a year. Case report 5 A case report published in the Journal of Dermatological Treatment documents the successful use of adalimumab to control symptoms and induce relapse for 72 weeks. "Adalimumab is ... approved for the treatment of moderate to severe rheumatoid arthritis ... and more recently for the treatment of psoriatic arthritis". See also List of cutaneous conditions Psoriasis References External links Psoriasis

Pustular psoriasis of pregnancy (impetigo herpetiformis)--case report.

Impetigo herpetiformis is a rare dermatosis of pregnancy with typical onset during the last trimester of pregnancy and rapid resolution in the postpartum period. Clinically and histologically, it is consistent with pustular psoriasis. This similarity has led some authors to name the disease "the pustular psoriasis of pregnancy". We report the case of a patient who developed impetigo herpetiformis in two successive pregnancies.

Impetigo herpetiformis

Impetigo herpetiformis is a form of severe pustular psoriasis occurring in pregnancy which may occur during any trimester. It is the only well known pustular psoriasis which is treated with steroids. See also Dermatoses of pregnancy List of cutaneous conditions Notes References External links Pregnancy-related cutaneous conditions Psoriasis Pathology of pregnancy, childbirth and the puerperium

Generalized pustular psoriasis of pregnancy (impetigo herpetiformis).

A 17-year-old woman had a sudden eruption of pustules in her intertriginous areas as well as of erythematosquamous plaques on the scalp, elbows, palms and soles in the third trimester of her first pregnancy. Histopathological evaluation of a biopsy revealed typical changes of pustular psoriasis with parakeratosis and abscesses of neutrophils (Kogoj's spongiform pustules). The diagnosis of pustular psoriasis was established by the typical clinical and histopathological findings. Laboratory parameters showed a highly elevated blood sedimentation rate, hypoferric anemia and decreased albumin levels. Serum concentrations of parathormone and its metabolites were normal. After systemic treatment with glucocorticosteroids and antibiotics, the lesions improved but did not clear. After delivery of a healthy boy, therapy was switched to retinoid photochemotherapy with isotretinoin and PUVA that resulted in rapid and complete clearing of the eruption. The coincidence of plaque-type psoriasis and a pustular eruption as described previously in impetigo herpetiformis supports the view that this dermatosis of pregnancy is a variant of generalized pustular psoriasis.

Generalized Pustular Psoriasis -- Epidemiology -- Age at Onset

The incidence peaks between 40 and 59 years of age, but infantile and juvenile cases are also reported. The age at onset tends to be earlier in those with pure generalized pustular psoriasis without plaque psoriasis.

Generalized pustular psoriasis

According to the article by the University of São Paulo, mentioned above, "The onset of childhood GPP is generally abrupt and accompanied by toxic features." The original acute episode usually lasts a few days, but "repeated waves of inflammation and pustulation may follow." It is important that the disease is managed immediately in order to prevent life-threatening complications, such as infection or [sepsis]. Other complications include "metabolical, hemo-dynamic, and thermoregulatory disturbances" which occur as a result of "alterations of the epidermal barrier." See Case Report 3 Circinate and annular This type of psoriasis appears as round lesions. It begins as discrete areas that become raised and swollen. Pustules appear at the edges of the round lesions, creating rings. The pustules then dry out and leave a trail of scale as the lesion grows. See Case Report 4

Localized pustular psoriasis

Localized pustular psoriasis presents as two distinct conditions that must be considered separate from generalized psoriasis, and without systemic symptoms, these two distinct varieties being pustulosis palmaris et plantaris and acrodermatitis continua. See also Psoriasis Skin lesion References Psoriasis

Annular pustular psoriasis

Annular pustular psoriasis is a rare variant of pustular psoriasis, having an annular, or circinate, lesion morphology that may appear at the onset of pustular psoriasis, with a tendency to spread and form enlarged rings. See also Psoriasis List of cutaneous conditions References External links Psoriasis

Early onset plaque psoriasis may develop into pustular psoriasis after years, the cause usually being steroids or any other environmental factor or the onset maybe de novo , usually after an infection. In either form, the earliest symptom is burning sensation in the skin, which becomes dry and tender. These danger signs, not found in all cases, are followed by a sudden onset of high fever and severe malaise. Pre-existing lesions develop into minute pustules. Worsening of erythema occurs, and pustules spread to involve the previously normal skin, mostly the flexures and genital regions. Pustules may be in the form of discrete pustules, lakes of pus, circinate lesions, erythematous plaques covered with pustules, or a generalized erythroderma. Pustules appear in a series, and dried pustules start exfoliating. The nail changes include thickening and subungual areas of pus. The oral mucosa and tongue may also be involved. The disease process may resolve within a few days or weeks; psoriasis can revert back to its normal state or erythroderma can develop.

Generalized pustular psoriasis

Generalized pustular psoriasis (GPP) is an extremely rare type of psoriasis that can present in a variety of forms. Unlike the most general and common forms of psoriasis, GPP usually covers the entire body and with pus-filled blisters rather than plaques. GPP can present at any age, but is rarer in young children. It can appear with or without previous psoriasis conditions or history, and can reoccur in periodic episodes. Signs and symptoms GPP presents as pustules and plaques over a wide area of the body. It differs from the localized form of pustular psoriasis in that patients are often febrile and systemically ill. However, the most prominent symptom, as described in the Archives of Dermatology, is "sheeted, pinhead-sized, sterile, sub-corneal pustules". The IPC roundtable adds that these pustules often occur either at the edges "of expanding, intensely inflammatory plaques" or "within erythrodermic skin".

Impetigo herpetiformis: menstrual exacerbations for 7 years postpartum.

Impetigo herpetiformis (IH) is a rare pustular dermatosis that shares striking clinical and histological similarities to generalized pustular psoriasis. The case of a 26-year-old primigravida with IH progressing in the 30th week of her pregnancy is presented. The peculiarity of our presentation relies on the reappearance of the disease postpartum. Monthly exacerbations during menstruation lasted for 7 years. Some probable clues regarding the pathogenesis of IH are suggested.

Elderly-Onset Generalized Pustular Psoriasis without a Previous History of Psoriasis Vulgaris.

Generalized pustular psoriasis (GPP) is characterized by sudden fever and extensive erythema with pustules and occurs in patients with or without preceding psoriasis vulgaris. We report an 83-year-old man showing irregularly shaped erythema with pustules on the trunk and extremities. He initially had no fever and came to our clinic a few days after the onset of the skin lesions because of high fever and general malaise. We found an extension and new development of erythema and pustules on the whole body. The patient also manifested night delirium. Histological examination revealed neutrophil infiltration into the upper epidermis, which formed a spongiform pustule of Kogoj. Pustular fluid cultures were negative for bacteria. We diagnosed GPP without preceding psoriasis vulgaris. Mutation analysis revealed no significant mutations in IL36RN and CARD14. Previous reports indicated that onset of GPP at the age of 83 years is definitely rare. In older individuals, general disease characteristics include an atypical clinical course, an especially slow appearance and cure, and mental disorder. Our case also revealed such characteristics. Thus, it is necessary to be aware of the clinical course and mental problems in elderly patients with GPP.

Erosive pustular dermatitis of the scalp presents with pustules, erosions, and crusts on the scalp of primarily older Caucasian females, and on biopsy, has a lymphoplasmacytic infiltrate with or without foreign body giant cells and pilosebaceous atrophy. See also Skin lesion Cicatricial alopecia List of cutaneous conditions References Conditions of the skin appendages

Psoriasis

The five main types of psoriasis are plaque, guttate, inverse, pustular, and erythrodermic. Plaque psoriasis, also known as psoriasis vulgaris, makes up about 90% of cases. It typically presents as red patches with white scales on top. Areas of the body most commonly affected are the back of the forearms, shins, navel area, and scalp. Guttate psoriasis has drop-shaped lesions. Pustular psoriasis presents as small, noninfectious, pus-filled blisters. Inverse psoriasis forms red patches in skin folds. Erythrodermic psoriasis occurs when the rash becomes very widespread, and can develop from any of the other types. Fingernails and toenails are affected in most people with psoriasis at some point in time. This may include pits in the nails or changes in nail color.

Generalized pustular psoriasis

Eugene M. Farber, MD and colleagues provide a description of von Zumbusch psoriasis in "Pustular Psoriasis", published in Cutis. They describe the pattern as having "waves of widespread or universally fiery redness". The affected areas are "painful and tender". Small sub-corneal pustules form, with sizes originally between 1 and 10 mm in diameter. These pustules may merge to form "yellow-green lakes of pus". The pustules dry out, and "Waves of scarlatiniform [resembling scarlet fever] peeling follow, removing the desiccating pustules". In regards to the onset, the von Zumbusch form may "supervene on any previous pattern of psoriasis". It also may or may not recur periodically. Generalized pustular psoriasis of pregnancy (Impetigo herpetiformis) This form of GPP tends to have symmetrical and grouped features. It usually onsets early in the third trimester of pregnancy, and generally persists until the child is born, but occasionally long after.

[Impetigo herpetiformis and PUVA-treatment (author's transl)].

Report on a 20 years old pregnant woman, who fulfilled the criteria of the impetigo herpetiformis as well as later those of the pustular psoriasis Zumbusch in her clinical course. The impetigo herpetiformis is interpreted as a variant of the pustular psoriasis occurring during the pregnancy with lowered calcium-level, which increases the endogeneous eruption pressure. After negative attempts of treatment with Prednisolon, antibiotics, and later with Methotrexat an excellent therapeutic effect could be achieved by oral PUVA-treatment.

A rare subacute form represents generalized pustular psoriasis in infancy and early childhood. The disease starts as discrete areas of erythema which become elevated. Pustules appear peripherally on the advancing edge, becoming dry and shedding in the form of scales as the lesion gradually progresses. There are no accompanying systemic symptoms.

[Generalized pustular psoriasis in siblings].

Generalized pustular psoriasis in siblings, 31-year-old male and 26-year-old female, is presented. In both cases, pustular lesions appeared in childhood and typical eruption of psoriasis vulgaris was not observed during their clinical course. Cholecystitis and chronic tonsillitis of the brother and periodontitis and chronic tonsillitis of the sister were considered to be possible provocative factors. HLA-A24, Bw52-, DR2, as the common HLA haplotype in our cases, was estimated.

Pustular psoriasis

The term pustular psoriasis is used for a heterogeneous group of diseases that share pustular skin characteristics. Signs and symptoms Characteristics may vary according to the subtype of pustular psoriasis. For example, it can be localized, commonly to the hands and feet (localized pustular psoriasis), or generalized with widespread patches appearing randomly on any part of the body (generalized pustular psoriasis). However, all forms of pustular psoriasis share in common the presence of red and tender blotchy skin covered with pustules.

Psoriasis Vulgaris in Children - Case Presentation.

A seven-year-old girl, with erythematous-squamous rash, was admitted to our clinic to decide upon the diagnosis and treatment, being transferred from a county hospital. Heredo-collateral antecedents - an aunt, related to her mother, with psoriasis. When admitted, the patient presented prominent non-pruriginous erythematous plaques, clearly marked and covered by thick, silvery-white scales, easily exfoliating, all over at the level of: scalp, earlobes, neck, torso, limbs, periungual, axillary and genital areas. The dermatological examination: psoriasis vulgaris in patches and plaques, a diagnosis also confirmed histopathologically. Using a local dermatologic treatment, the evolution was favorable, the patient initially presenting thick squamae, then, gradually, there occurred the psoriasis whitening. We presented this case since psoriasis is rarely met at this early age.

Generalized pustular psoriasis

Causes Most cases of generalized pustular psoriasis present in patients with existing or prior psoriasis conditions. However, there are many cases of GPP that arise without a history of psoriasis. The Department of Dermatology of the University of São Paulo proposed a classification for these two conditions. Pso+ represents patients with a personal history of psoriasis and pso- represents patients with no history of psoriasis. They also identified a common factor among patients in each group: In the pso+ group, the most common precipitating factor is corticosteroid withdrawal. In the pso- group, the most common precipitating factor is infection. In a large portion of cases, the disease is brought on by some triggering factor. Through research and observation, many of these factors have been identified. The following table, from an article in Cutis, lists a few factors that have been observed as influential in the onset of GPP.

Human Orf: An Under-recognized Entity.

Dear Editor, Orf, also called contagious ecthyma, contagious pustular dermatitis, sore mouth, or scabby mouth, is a highly contagious zoonotic disease which is caused by a double-stranded DNA virus, ORFV (Parapoxvirus genus of the family Poxviridae) (1). The infection is endemic to sheep and goats, and humans are infected either through direct transmission from active lesions on infected animals or through contact with fomites (2). Orf is an occupational hazard and the population at risk includes shepherds, butchers, farmers, wool shearers, and veterinarians (2,3). Professionals rarely seek medical attention as they are aware of its benign nature (4). A 59-year-old woman presented with two painful plaques involving the dorsal aspect of her right thumb and the first interdigital space of the left hand. On examination, targetoid appearance with a central umbilication surrounded by a violaceous bullous halo was observed (Figure 1). The patient had been raising goats on her farm that recently presented udder and perioral crusted lesions. She did not wear gloves while performing this task. A skin biopsy was performed and showed elongation of the rete ridges, edematous papillary dermis, and eosinophilic intracytoplasmic inclusions in vacuolated cells (Figure 2). A diagnosis of human orf was established and the patient was started on a topical antiseptic solution to prevent secondary infection. The lesions healed without scarring after 6 weeks. Orf is characterized by one or multiple nodules on the hands and fingers, but also on the feet, legs, neck, and face. After an incubation period of 3-7 days, the lesions evolve through six clinical stages (2-4): (1) maculopapular stage (days 1-7), with erythematous macules or papules; (2) target stage (days 7-14), with necrotic center and red outer halo; (3) acute stage (days 14-21), in which the nodule begins to weep; (4) regenerative stage (days 21-28), in which the nodule becomes dry; (5) papilloma stage (days 28-35), where the lesion become papilloma-like and forms a dry crust; (6) regression stage (after 35 days). The lesions may be accompanied by lymphangitis, lymphadenopathy, malaise, fever, erysipelas, and occasionally erythema multiforme and bullous pemphigoid (3). Orf is usually a clinical diagnosis (2-4). The characteristic clinical appearance and location of the lesions along with the history of contact with infected animals is sufficient to establish a diagnosis. The differential diagnosis includes milker's nodule, cutaneous anthrax, neutrophilic dermatosis, atypical mycobacterial infection, cutaneous leishmaniasis, pyogenic granuloma, keratoacanthoma, and fungal infection (4,5). Further investigations are performed only when the diagnosis is in doubt and include electron microscopy, virology, enzyme-linked immunosorbent assay, or PCR-based approaches (4). The histological findings depend on the stage of the lesion and include eosinophilic inclusion bodies, epidermal necrosis, vacuolated keratinocytes, a dense mixed dermal infiltrate, and delicate finger-like projections in the epidermis (6).There is no specific treatment since the disease resolves spontaneously within 6-8 weeks, but successful application of cryotherapy, topical imiquimod, and cidofovir has been reported without supporting evidence (4). Surgical debridement should be avoided because it prolonged the recovery period (5). For prevention, wearing nonporous gloves, washing after handling, and isolation of infected animals is effective (2,4). In the present case, the diagnosis of orf was established in a straightforward manner after a good clinical examination and occupational history, allowing us to reassure the patient on its benign nature. The knowledge of this diagnosis prevents multiple complementary investigations (blood tests, histopathology, skin cultures, PCR detection, and electron microscopy) and unnecessary overtreatment. Although a rare entity, the predominant hand involvement in professionals can have significant morbidity that reflects on their productivity and quality of life. This reinforces the need for using appropriate measures to prevent animal-to-human transmission.


In the data you provide there are no clinical risk factors for osteoporosis prior to the current disease. Since a prolonged and high-dose prednisone regimen will be established, it is advisable, in addition to the non-pharmacological preventive measures, to initiate treatment in any case to minimize the secondary loss of bone mass that occurs with the administration of glucocorticoids (and, above all, in the first months). Therefore, and for this reason alone, options 1, 2 and 5 would be discarded (the three of them have another conditioning factor). In this context, and in the case of a person over 65 years of age, an appropriate attitude would be to administer calcium supplements (corticosteroids are osteopenizantes because they produce, among other mechanisms, a negative balance of this element) and vitamin D. The option of associating a bisphosphonate could also be considered, but calcium supplementation is missing in proposal 3.

In the data you provide there are no clinical risk factors for osteoporosis prior to the current disease. Since a prolonged and high-dose prednisone regimen will be established, it is advisable, in addition to the non-pharmacological preventive measures, to initiate treatment in any case to minimize the secondary loss of bone mass that occurs with the administration of glucocorticoids (and, above all, in the first months). Therefore, and for this reason alone, [HIDDEN] (the three of them have another conditioning factor). In this context, and in the case of a person over 65 years of age, an appropriate attitude would be to administer calcium supplements (corticosteroids are osteopenizantes because they produce, among other mechanisms, a negative balance of this element) and vitamin D. The option of associating a bisphosphonate could also be considered, but calcium supplementation is missing in proposal 3.

A 75-year-old woman, with menopause at age 52, with no family or personal history of fracture, diagnosed with temporal arteritis, who is going to start treatment with high-dose prednisone and expects to be treated for at least one year. The delay of densitometry (DXA) in her center is 4-5 months. Preventive treatment for osteoporosis is considered. Which of the following is the most appropriate approach?

Assess absolute risk of fracture using the FRAX questionnaire without BMD and treat only if it is high.

Start treatment with bisphosphonates and vitamin D (800 IU/day).

Administer calcium supplementation (1g) and vitamin D (800 IU/day).

Assess for osteopenia on radiographs and treat if present.

A cost effectiveness analysis of calcium and vitamin D supplementation, etidronate, and alendronate in the prevention of vertebral fractures in women treated with glucocorticoids.

To assess the relative costs and benefits of calcium and vitamin D supplements, cyclic etidronate, or alendronate in the prevention of vertebral fractures for women and with normal bone density and osteopenia who are about to initiate moderate dose glucocorticoid treatment. Using a decision analysis model, we evaluated the following patients: 4 hypothetical cohorts: 30-yr-old women with normal lumbar spine (LS) bone mineral density (BMD) (t score = 0), 50-yr-old women with borderline osteopenia (t score = -1), 60-yr-old women with moderate osteopenia (t score = -1.5), and 70-yr-old women with severe osteopenia (t score = -2) treated with a mean prednisone dose of 10 mg/day for one year. The main outcomes included the development of vertebral fractures 10 years after glucocorticoid treatment and at age 80 (life-time risk) and direct and indirect costs. At 10 years, calcium and vitamin D supplements decreased fracture rates by 30-50% at a minimal cost (US$800 or less per vertebral fracture avoided) or at a cost saving compared to no treatment for women with osteopenia (t score -1 to -2). Etidronate and alendronate are most cost effective in women with borderline osteoporosis (t scores of -1.5 and -2) in the 10 year analysis. In the life-time analysis, calcium and vitamin D treatment yielded a cost savings compared to no treatment for all groups with osteopenia. Etidronate decreased fracture rates further in all groups at a cost of less than $2,000 per fracture prevented. Alendronate reduced the fracture risk further at cost of $3,000-7,000 per fracture avoided. Calcium and vitamin D supplements and low cost bisphosphonate regimens such as cyclic etidronate decrease the life-time vertebral fracture risk at acceptable costs and should be considered when initiating glucocorticoid treatment for women who do not have osteoporosis.

[Bone protection in corticosteroid treated patients].

The Piedmont Group of Clinical Nephrology compared the activity of 15 nephrology centers in Piedmont and Aosta Valley as regards bone protection in patients on corticosteroids therapy. Fracture prevalence shows great variability: in 4/15 centers (27%) no fractures were found, in 6/15 centers (40%) fractures were present in 1-4% of cases, in 1 center in 18% of patients. Clinical risk of fracture was based on sex, age and postmenopausal status in 11/14 of the centers (79%), history of fractures and bone disease in 4/14 centers (27%), smoking and alcohol consumption in 3 and 2 centers respectively, glucocorticoid dose and duration in 4, in children bone age and calcium phosphorus status. Dual energy X-ray absorptiometry was performed in 12 centers based on risk factors, in 8 (57%) DXA was performed during the follow-up, in 4 it was performed after 12 months and in 2 after 2-3 years. DXA is not prescribed in children. Only in one center, risk assessment is based on FRAX. Most of the patients are treated with vitamin D supplementation at a dose of steroids of 5 mg/d (80%). Calcium carbonate is used in 9 centers (60%), in two it is used only in the presence of low ionized calcium or bone mineral density. Bisphosphonates are used following AIFA prescription, in particular alendronate in all centers, risedronate in seven and denosumab in one. The analysis shows the great variability of the clinical and therapeutic approach regarding bone protection in patients on corticosteroids therapy, in Piedmont and Aosta Valley.

Real-world effectiveness of osteoporosis treatment in the oldest old.

We studied effectiveness of osteoporosis treatment in women older than 80 years, who often are not included in clinical trials. Treatments were as effective on bone density and fractures as in younger women. To study real-world effectiveness of osteoporosis treatment on BMD and fractures in the oldest old women (≥ 80 years) compared with women (60-79 years) in the clinical setting using Swedish health register data. National registers and data from DXA machines were used to study effectiveness of all available osteoporosis treatments in women 60-79 and ≥ 80 years using three approaches: (1) Total Hip BMD change up to 8 years after treatment start; (2) fracture incidence where patients served as their own controls, comparing the first 3 months after treatment start with the subsequent 12 months; and (3) comparison of fracture incidence post-fracture in women ≥ 80 years treated with osteoporosis treatment or calcium/vitamin D. Analysis 1: Total Hip BMD increased by up to 6.7% and 7.7% in women 60-79 and ≥ 80 years old, respectively. The mean increase in BMD was 1.1%-units per year in both age groups. Analysis 2: Relative to the 3-month baseline, fracture incidence decreased during the subsequent 12 months of treatment. Incidence rate ratios were estimated at 0.65, 0.74, 0.29, and 0.81 for any, hip, vertebral, and non-hip-non-vertebral fracture, respectively. Analysis 3: A 24-month incidence of any fracture in women ≥ 80 years given post-fracture osteoporosis treatment was lower (HR = 0.78) than in women given calcium/vitamin D, but treatment allocation was not random, with lower mortality (HR = 0.51) in patients receiving OP treatment. Osteoporosis medication in women > 80 years in clinical practice likely works, and the magnitude of effect is similar to what was estimated in younger women. The choice between osteoporosis treatment and calcium/vitamin D after fracture in women ≥ 80 years is not random but appears associated with the patient's health status and presence of vertebral fractures, rather than the known risk profile of sustaining a fracture at a high age.

Management of osteoporosis in primary care before and after the result of densitometry: treatments in real practice versus the recommended by guidelines. CANAL study.

To analyze the requirements for osteoporosis (OP) treatment of primary care physicians (PCP), before and after knowing the result of a bone densitometry (DXA). We studied 50 years older women from two Spanish health areas (Canary Islands and Alicante). The FRAX risk factors were collected and we reviewed the requirements for OP treatment before DXA and in the subsequent months (bisphosphonates, strontium, raloxifene/bazedoxifene, estrogens, parathyroid hormone). To evaluate the appropriateness of treatment we used published guidelines. A high risk for hip fracture was considered if FRAX ≥ 3% or the patient had a history of fragility fracture We included 339 women (mean age: 63 years). Before DXA, 14% of Canarias and 58% of Alicante were receiving treatment. Thirty seven percent of treated patients and 26% of the untreated patients had a high fracture risk before DXA. The average FRAX for a high risk of fracture and hip fracture was 5.6% and 2%, respectively. After DXA, the percentage of treated patients rose from 35 to 39%: increasing from 14 to 28% in the Canary Islands and decreasing from 58 to 51% in Alicante. Overall, treatment was received by 64% of patients with OP, 38% of patients with osteopenia and 15% of those with normal DXA. When the OP treatment guidelines were applied, we found that 7% needed treatment according to the most restrictive guidelines and 43% according to the most flexible guidelines. There is great variability in treatment for OP prescribed before after DXA between GP. A broad consensus guideline between different specialties is required to optimize clinical practice.

Suboptimal osteoporosis evaluation and treatment in older men with and without additional high-risk factors for fractures.

We compared osteoporosis case-finding, evaluation and treatment in groups of Older Men and Older Women with age alone as a significant risk for fracture and Older Men with Higher Risk (older men additionally having previous hip fracture, corticosteroid use or androgen deprivation therapy). We studied 13,704 older men and women (≥70 years old) receiving care at a Veterans Affairs medical center from January 2000 to August 2010 whose 10-year hip fracture risk was assessed by limited FRAX score. The main outcome measures were the proportion of patients who had bone mineral density (by dual-energy X-ray absorptiometry [DXA]) and serum 25-hydroxy vitamin D (25-OH D) measurements performed, and calcium/vitamin D or bisphosphonates prescribed. The proportion of men with a 10-year hip fracture risk ≥3% with age alone as a risk was 48% and 88% in men aged 75-79 and ≥80 years, respectively. Compared with Older Women, fewer Older Men underwent DXA (12% vs 63%, respectively) and 25-OH D measurements (18% vs 39%), and fewer received calcium/vitamin D (20% vs 63%) and bisphosphonate (5% vs 44%) prescriptions. In Older Men with Higher Risk category, the proportion of men with 10-year hip fracture risk ≥3% ranged from 69% to 95%. Despite a higher risk and expectation that this group would have greater case detection and screening, few Older Men with Higher risk underwent DXA screening (27%-36%) and 25-OH D measurements (23%-28%), and received fewer calcium/vitamin D (40%-50%) and bisphosphonate (13%-24%) prescriptions. Considering the known morbidity and mortality, our findings underscore the need for improved evaluation and management of osteoporosis in older men at high risk for fracture.

Efficacy of risedronate in men with primary and secondary osteoporosis: results of a 1-year study.

Osteoporosis is prevalent in men with an estimated one in eight men older than 50 years suffering from osteoporotic fracture, and a higher mortality rate after fracture among men compared with women. There are few approved therapies for osteoporosis in men. This observational study assesses the efficacy and safety of risedronate in the treatment of men with primary and secondary osteoporosis. A single-center, open label, randomized, prospective 1-year study was conducted in men with primary or secondary osteoporosis. Patients were randomized to risedronate (risedronate 5 mg/day plus calcium 1,000 mg/day and vitamin D 800 IU/day) or control groups (alfacalcidol 1 mug/day plus calcium 500 mg/day or vitamin D 1,000 IU/day plus calcium 800 mg/day). Bone mineral density (BMD) measurements, X-rays of the spine, a medical history and physical exam, and patient self-assessments of back pain were performed at baseline and 12 months. Blinded semi-quantitative fracture assessment was conducted by a radiologist. A total of 316 men with osteoporosis were enrolled in the trial (risedronate, n=158; control, n=158). At 1 year lumbar spine BMD increased by 4.7% in the risedronate group versus an increase of 1.0% in the control group (P<0.001). Significant increases in BMD at the total hip and femoral neck were also observed with risedronate compared with the control group. The incidence of new vertebral fracture in the risedronate group was reduced by 60% versus the control group (P=0.028). Daily treatment with risedronate for 12 months significantly increased BMD at the lumbar spine, femoral neck and total hip and significantly reduced the incidence of new vertebral fractures. This is the first prospective, randomized, controlled trial to demonstrate a significant reduction in vertebral fractures in 1 year in men with primary or secondary osteoporosis.

[CBO guideline 'Osteoporosis' (second revision].

Risk factors for osteoporotic fractures that can be used for case-finding according to the recent guidelines from the Dutch Institute for Health Care Improvement (CBO) include: a vertebral fracture, a fracture past the age of 50, a positive family history, low body weight, severe immobility and the use of corticosteroids. Measurement of bone mineral density (BMD) is only recommended for case-finding and not for population screening. Measurement of the BMD is advised in women > or = 50 years of age with a fracture, women with a vertebral fracture regardless of age, women > or = 60 years of age with three of the following risk factors, and women > or = 70 years of age with two of the following risk factors: positive family history, low body weight and severe immobility. Persons with less than 1000-1200 mg calcium in their daily food who are using corticosteroids, persons with osteoporotic fractures and persons who are being treated with drugs for osteoporosis are eligible for calcium supplementation. Vitamin D supplementation is recommended for persons who do not come outdoors. For the drug treatment of osteoporosis in the first years after menopause, oestrogens, tibolone and raloxifene may be used. It is recommended that postmenopausal women with one or more osteoporotic vertebral fractures or an increased risk and a T-score below -2.5 be treated with a bisphosphonate. Patients who are expected to be treated with > or = 15 mg prednisolone equivalent per day for more than 3 months and postmenopausal women and older men (> or = 70) who will be treated with > or = 7.5 mg prednisolone equivalent per day should be started on a bisphosphonate as soon as possible. Other patients who will be treated with > or = 7.5 mg prednisolone equivalent per day should take a bisphosphonate if their Z-score is below -1 or their T-score is below -2.5.

Low rate of densitometric diagnosis and treatment in patients with severe osteoporosis in Colombia.

Our study describes the clinical characteristics of patients with fragility fractures. It also shows there is a low knowledge about osteoporosis and its relation to fractures, in addition to the very poor adherence to medical advice and treatment. Osteoporosis is a systemic skeletal disease associated with an increased risk of fragility fractures and is a public health problem worldwide due to population aging. Early osteoporosis diagnosis and treatment is very important for reducing the incidence of fragility fractures and the resulting complications. Our study describes the clinical characteristics of patients with fragility fractures and their risk factors, evaluates the level of knowledge that patients have about osteoporosis, and follows-up on each case to establish if, after the fracture, a densitometric diagnosis was made and the patient received specific treatment in his outpatient follow-up through his health insurance plan. A descriptive cross-sectional study was carried out in a university hospital in Bogotá, Colombia. The data was collected by means of a questionnaire, administered to all patients admitted by the orthopedic emergency department with a diagnosis of fragility fracture. After discharge, a telephone follow-up was done every 3 months for 1 year, and patients were asked if they had already had the dual X-ray absorptiometry (DXA) scan and if they had begun osteoporosis treatment. A total of 111 patients with an average age of 74.4 years (± 11.3 years), of which 84 (75.6%) were women, all consulted for osteoporotic fracture at the orthopedic emergency department of the hospital. Hip fracture was the most frequent (51.4%), followed by vertebral (23.4%), wrist (22.5%), and humerus (4.5%) fracture. A total of 49.5% (n = 55) of the patients did not know what osteoporosis is; 58.6% (n = 65) did not know that fracture is the main complication of this disease, and 62.2% (n = 69) did not associate fractures with osteoporosis. All patients were educated about osteoporosis and the importance of diagnosing and treating it. Patients were given a medical order to have a DXA scan upon discharge; however, only 24.3% (n = 27) had the DXA scan in the first year of the fracture. A total of 33.3% (n = 37) received calcium plus vitamin D, and only 9.9% (n = 11) received osteoporosis treatment (7 bisphosphonate patients and 4 denosumab). No patient received osteoformative therapy. Our study shows that Colombian patients have little knowledge about osteoporosis and its relationship with fragility fractures. It also shows that densitometries are not done and, what is worse, patients with a diagnosis of fracture have limited access to treatment after discharge.

Osteoporosis: trials and tribulations.

A 30-50% reduction in fracture risk produced by a drug is biologically "worthwhile." The detection of this benefit, when truly present, is a challenge requiring large studies of 3-5 years' duration, because only a small number of women at risk actually sustain a fracture during this time. For example, in any year, fractures occur in 1-2 per 100 women approximately 65 years of age, 6-10 per 100 women approximately 75 years of age, and only 1-2 per 2,000 of the 15% of women < 60 years of age with osteoporosis. An appreciation of this low annual event rate is important because (1) it helps patients to understand their illness, (2) it determines the power of clinical trials, (3) it underscores the large numbers of patients that must be treated to prevent one fracture, and (4) it underscores the need for safety, particularly in groups at low absolute risk of fracture; all are exposed to drug side effects, and the vast majority derive no benefit from treatment because they would not have had a fracture without it, despite being at risk. Few studies have met the design requirements needed to identify the antifracture efficacy of a drug when it really exists, namely, (1) large patient samples randomized to treatment or placebo for 3-4 years, (2) blinding throughout follow-up, (3) statistical analyses of preplanned comparisons using intention to treat, and (4) avoidance of statistical analyses of associations discovered by post hoc analyses. Moreover, (5) few studies have assessed long-term safety and quality of life. Consequently, the uncertainty regarding efficacy and safety of available treatments may be more of a problem of the design, execution, and interpretation of the clinical studies than of the drugs themselves. In the reduction of vertebral fracture risk, the greatest optimism exists for hormone replacement therapy (HRT) and the bisphosphonates. HRT reduces bone turnover, increases bone mineral density (BMD), and decreases vertebral fracture rates by approximately 40%, even in women > 70 years of age. Reduction in hip fracture risk with HRT has been reported in observational studies. Two rigorously conducted studies provide credible evidence that the bisphosphonate alendronate reduces the risk of vertebral and hip fractures by approximately 40-50%. Etidronate, calcitonin, and 1,25-dihydroxyvitamin D3 may reduce risk of vertebral fracture; however, problems in study design leave uncertainty. Although 2 trials using fluoride suggest a reduction in fracture rates, the more rigorously conducted trials do not, despite having adequate power to do so. Calcium supplements are likely to slow bone loss, but reduction in fracture risk is uncertain. Vitamin D and calcium supplementation reduce risk of hip fracture in nursing home residents but not in community residents. There have been no studies of the efficacy of any treatment to prevent hip or vertebral fractures in men or in corticosteroid-related osteoporosis. The treatment of osteoporosis is becoming a reality. HRT and the bisphosphonates, particularly alendronate, appear to be the best options at present.

Osteoporosis

Studies of the benefits of supplementation with calcium and vitamin D are conflicting, possibly because most studies did not have people with low dietary intakes. A 2018 review by the USPSTF found low-quality evidence that the routine use of calcium and vitamin D supplements (or both supplements together) did not reduce the risk of having an osteoporotic fracture in male and female adults living in the community who had no known history of vitamin D deficiency, osteoporosis, or a fracture. The USPSTF does not recommend low dose supplementation (less than 1 g of calcium and 400 IU of vitamin D) in postmenopausal women as there does not appear to be a difference in fracture risk. A 2015 review found little data that supplementation of calcium decreases the risk of fractures. While some meta-analyses have found a benefit of vitamin D supplements combined with calcium for fractures, they did not find a benefit of vitamin D supplements (800 IU/day or less) alone. While supplementation does

3-year follow-up of 215 fracture patients from a prospective and consecutive osteoporosis screening program. Fracture patients care!

Fractures can be prevented if osteoporosis is identified and treated. Starting in 2002, we have been using a screening program in which patients between 50 and 75 years of age with a wrist, shoulder, vertebral, or hip fracture are assessed by DEXA of the hip and spine and if osteoporotic or osteopenic, they are encouraged to see a doctor of their own choice. The patients receive documents containing information, the results of DEXA, and a letter to present to their doctor with suggestions regarding blood tests and treatment. Here we report the 3-year follow-up regarding compliance to the recommended treatment. A questionnaire was sent to fracture patients who participated in the initial screening study from November 2002 through November 2003. Questions included whether they had seen a doctor, whether treatment had been initiated, and their opinions about osteoporosis. 215 of the 236 patients answered the questionnaire, with a mean follow-up of 39 months. 76/87 of those with osteoporosis, 70/99 of those with osteopenia, and 11/29 of those with normal BMD had seen a doctor. Anti-resorptive treatment was prescribed to two-thirds of the osteoporotic patients, to one-sixth of the osteopenic patients, and to none of the patients with normal bone density. Calcium-vitamin D supplementation as monotherapy was given to one-third of the osteoporotic patients, to half of the osteopenic patients, and to half of the normal patients. Only a few osteoporotic patients, one-third of the osteopenic patients, and half of the normal patients received no treatment. Compliance to treatment was 80% over 3 years in those treated. Most patients felt that they could influence their skeletal health. Screening of fracture patients for osteoporosis effectively identifies patients with low bone mineral density and the patient can be trusted to seek appropriate medical advice for treatment of osteoporosis. Based on the bone scan diagnosis, the treatment that these patients received reflects current treatment guidelines well.

Senile osteoporosis

Calcium and vitamin D3 intake from diet or supplementation are crucial in the ethiopathogenesis of this disease; therefore, the effective treatments should consist of non pharmacological methods (such as a modified diet with more calcium 1000–1500 mg/day and vitamin D3 intake of 600-800 IU/day, exercising, smoking cessation, and alcohol restriction), fall prevention, and individually chosen pharmacological intervention (antiresorptive agent like bisphosphonate or estrogen replacement therapy in women). Given bone fracture (hip, vertebrae, and colles) is a devastating complication of osteoporosis, vitamin D3 combined with calcium are used as primary prevention, along with alendronate, residronate, strontium and zoledronic acid which have proven efficacy in primary and secondary hip fracture prevention. The Institute of Medicine recommends a daily allowance of 800 IU of Vitamin D for people 70 and over, to get to a level of serum 25-hydroxyvitamin D (25OHD) of at least 20 ng/ml (50

Abaloparatide

Participants who completed 18 months of abaloparatide or placebo in the ACTIVE study were invited to participate in an extended open-labeled study - ACTIVExtend study (2012-2016). Subjects (n=1139) received additional 2 years of 70 mg of alendronate, Vitamin D (400 to 800 IU), and calcium (500–1000 mg) supplementation daily. Combined abaloparatide and alendronate therapy reduced significantly the incidence of vertebral and nonvertebral fractures. A clinical trial assessing the effectiveness of abaloparatide in altering spinal bone mineral density (BMD) in male subjects is expected to start in the first quarter of 2018. If successful, Radius Health aims to submit a sNDA to expand the use of abaloparatide-SC to treat men with osteoporosis. In addition to the injectable form of abaloparatide, a transdermal patch is also in development. Commercialization

High rates of undiagnosed and untreated osteoporosis in postmenopausal women receiving medical services in the area of Upper Silesia.

High social cost and high risk of disability make postmenopausal osteoporosis one of major public health problem in the 21<supst</sup century. The aim of this study was to assess frequency of undiagnosed and untreated osteoporosis in postmenopausal women in the Upper Silesia Region of Poland. Additionally, we compare estimation of the 10-year probability of major osteoporotic fractures (MOF) and hip fractures (HF) based on fracture risk assessment tool (FRAX) with and without bone mineral density (BMD). The survey included 450 postmenopausal women (age 65 ±11 years). A detailed questionnaire included demographic and anthropometric data, comorbidity, history of previous low-energy fractures, family medical history, and treatment for osteoporosis. The FRAX calculator was used to estimate the risk of MOF and HF. Osteoporosis was previously diagnosed in 23.7% women. Of those 70.2% were receiving vitamin D, 27% calcium preparations, 33% bisphosphonates, and 22% were untreated. Only 42.2% women with previous fractures had been diagnosed with osteoporosis and 42.8% received any treatment. 12.5% women with FRAX-BMD ≥ 10% had no risk factors of osteoporosis and < 10% risk of MOF and HF in FRAX without BMD. Osteoporosis often remains undiagnosed and untreated in postmenopausal women. There is a great need to popularize FRAX without BMD calculator among physicians, especially GPs, as the risk calculation justify the implementation of antiosteoporotic therapy. Women with burden of risk factors of fractures and borderline FRAX without BMD values, should be referred to a densitometry examination, as having greater risk of fracture than shown by FRAX without BMD.

Anti-resorptive therapy for the prevention of postmenopausal osteoporosis : when should treatment begin?

Osteoporosis is a condition associated with decreased bone strength and an increased fracture risk. It may be defined based on bone mineral density (BMD) with a T-score at the hip or spine of less than -2.5 standard deviations in young healthy individuals or from an osteoporotic fracture (i.e. a fracture occurring after low-energy trauma or no apparent trauma). Risk factors predisposing to fractures include: increasing age; female gender; low BMD; a prior fragility fracture; a family history of fragility fractures; low bodyweight; lack of estrogen in women (i.e. post menopause); corticosteroid use; smoking; a number of diseases; deficiency in calcium and vitamin D; an increased risk of falls (i.e. impaired vision); immobilization; and Caucasian race. The more risk factors that are present the higher the risk of fractures over the following 10 years. The need to initiate preventive therapy with anti-osteoporotic treatment increases steeply with the absolute fracture risk. Indications for referral for dual energy x-ray absorptiometry measurement of BMD include: age >65 years; age <65 years in postmenopausal women with any of the risk factors already mentioned; premature menopause (<45 years); prolonged amenorrhea (>1 year) in younger women; fragility fractures; and diseases or conditions known to lead to osteoporosis.Anti-resorptive therapies include calcium plus vitamin D, bisphosphonates (alendronate, etidronate, risedronate, ibandronate), selective estrogen receptor modulators (raloxifene), hormone replacement therapy, and calcitonin. Guidelines from several countries on when to initiate anti-resorptive therapy state that therapy may be started in patients with a prior fragility fracture (some guidelines state that in this situation no BMD measurements are necessary) or in patients with a T-score of less than -2.5 (some guidelines state that additional risk factors need to be present in this situation). Some guidelines state that anti-resorptive therapy may be initiated in patients with a T-score in the osteopenic range (from -1 to -2.5, i.e. not frank osteoporosis) in the presence of other risk factors. The cost effectiveness of anti-resorptive therapy increases with the absolute fracture risk. In some scenarios, treatment with bisphosphonates may be cost effective in a 50-year-old woman with an absolute hip fracture risk of >or=1.1% over the next 10 years.

Canadian health claims for food

In total, 63 897 individuals were analysed, most of whom were women (n=58 785 [92%]) with a mean age of 67.8 years (SD 9.7). In trials that reported fracture as an outcome (17 trials, n=52 625), treatment was associated with a 12% risk reduction in fractures of all types. In trials that reported bone-mineral density as an outcome (23 trials, n=41 419), the treatment was associated with a reduced rate of bone loss of 0.54% (0.35–0.73; p<0.0001) at the hip and 1.19% (0.76–1.61%; p<0.0001) in the spine. The fracture risk reduction was significantly greater (24%) in trials in which the compliance rate was high (p<0.0001). The treatment effect was better with calcium doses of 1200 mg or more than with doses less than 1200 mg (0.80 vs 0.94; p=0.006), and with vitamin D doses of 800 IU or more than with doses less than 800 IU (0·84 vs 0·87; p=0·03).

The clinician's guide to prevention and treatment of osteoporosis.

Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.

The cost effectiveness of bisphosphonates for the prevention and treatment of osteoporosis: a structured review of the literature.

Osteoporotic fragility fractures constitute a significant public health concern. The lifetime risk of any osteoporotic fracture is very high (40-50% in women and 13-22% in men). Fractures are associated with significant mortality and morbidity and represent a substantial economic burden to society. Bisphosphonates (alendronate, etidronate, risedronate and ibandronate) are indicated for the treatment and prevention of osteoporosis but are costly compared with other treatments, such as vitamin D and calcium. Our search identified 23 studies evaluating the cost effectiveness of bisphosphonate therapy for the treatment and prevention of fragility fractures; these studies were from five geographical areas and employed a variety of comparators and assumptions. We identified 11 studies investigating bisphosphonates in women with low bone mineral density (BMD) [T-score >2.5 standard deviations {SDs} below normal {mean} peak values for young adults] and previous fractures, five studies investigating bisphosphonates in women with low BMD and no previous fracture, one study of bisphosphonates in women with osteopenia, five studies involving screening and two studies of bisphosphonates in special populations (women initiating corticosteroid treatment and men). In women with low BMD and previous fractures, bisphosphonate therapy was most cost effective in populations aged > or =70 years and was unlikely to be cost effective in populations aged < or =50 years. There was uncertainty concerning the cost effectiveness of bisphosphonates in such populations aged 60-69 years. In women with low BMD without previous fractures, treatment with alendronate or risedronate appeared to be cost effective across countries (UK, US, Denmark), but there was some uncertainty about the cost effectiveness of etidronate in patients in the highest age groups. Identifying risk factors for fractures through means such as spine radiographs to detect vertebral deformities improves the cost effectiveness of treatment. In women with osteopenia, alendronate therapy may be cost effective in women with a T-score of -2.4SD in the US. Screening for low BMD and treatment with alendronate or etidronate appears to be cost effective in postmenopausal women in general and in women with rheumatoid arthritis initiating corticosteroid therapy. Alendronate therapy without screening was also shown to be potentially cost effective in certain at-risk male populations, as well as in women initiating corticosteroid therapy after the age of 40 years. Decision makers in the US, UK and Sweden should consider funding the use of bisphosphonates for the prevention and treatment of osteoporosis in women aged >70 years, particularly if they have other risk factors for fracture. Further studies are required to make more definitive conclusions in other countries and patient populations. Screening strategies for low BMD followed by bisphosphonate treatment should also be considered in the general female population aged >65 years in the UK and US and in patients with rheumatoid arthritis initiating corticosteroid therapy.

[Glucocorticoids and osteoporosis].

Treatment with glucocorticoids (GC) has no alternative in many medical disciplines for their anti-inflammatory and immunosuppressive effect. However, osteoporosis and the related fractures are a serious complication brought about by long-term GC therapy. The risk of fractures, especially of the vertebras and the ribs, becomes higher as early as in the first months of oral GC therapy. It grows in proportion to the daily dose of GC, and is present even if low doses are administered (2.5-7.5 mg of prednisone per day). Decreasing bone density (BMD) is not accountable for the higher risk of fractures in GC therapy and fractures occur with higher values of BMD than in primary osteoporosis. There is still no tool that we could use to quantify the changes in the bone quality and the increased risk of fracture in clinical practice. The principal mechanism by which GC induces osteoporosis is inhibition of bone formation caused by the suppression of osteoblastogenesis as well as the activity of functional osteoblasts, with accelerated osteocyte and osteoblast apoptosis. There are significant differences between individuals in terms of GC sensitivity, the reasons of which have not yet been explained. Prior to planned long-term GC therapy (> 3 months) with daily doses higher than 2.5 mg of prednisone p.o. (or higher doses of inhaled GC), it is recommended to perform a densitometry exam using dual-energy X-ray absorptiometry (DXA) in the lumbar region of the spine and femoral collum to evaluate additional risk factors of osteoporosis and fractures for a more precise estimate of the risk of fracture in the specific patient. Sufficient intake of calcium (1,000-1,500 mg of elementary calcium per day) and of the vitamin D (800 IU per day) should be assured in all patients treated by GC. Endogenous production of sexagens should be evaluated and possible substitution therapy should be considered in premenopausal women and younger men. Today, bisphosphonates can be given to patients with a high risk of fracture, the effects of which in preventing the decrease of BMD and vertebral fractures have been documented in randomised clinical studies, even though the evaluation of the risk of fractures was not the primary endpoint of those studies. However, in view of the antiremodelling effect of bisphosphonates, it is clear that this therapy does not eliminate the cause of GC induced osteoporosis and drugs with stimulating effect on osteoblasts will certainly be preferred in the future. Very promising are the first clinical studies of injection parathormone (PTH 1-34) which stimulated bone formation in a continuing GC treatment.

Use of matched historical controls to evaluate the anti-fracture efficacy of once-a-week risedronate.

Placebo controls are essential to assess anti-fracture efficacy of new osteoporosis therapies, but inclusion of a placebo arm in a subsequent clinical trial may be limited by practical or ethical considerations; in these cases, use of an historical control may be appropriate. A recent active-controlled study of risedronate 35 mg once a week demonstrated that this regimen produces increases in bone mineral density (BMD) that are comparable to those seen with the risedronate 5 mg daily dose, which has proven anti-fracture efficacy. To assess the anti-fracture efficacy of this new regimen, we have analyzed the fracture data collected in an active controlled study of risedronate dosing regimens (the Once-a-Week study) using matched historical control data from previous placebo-controlled trials. Women in the Once-a-Week study were matched for age, years since menopause, BMD, and prevalent vertebral fracture status, with placebo patients in the Vertebral Efficacy of Risedronate Therapy (VERT) trials forming an historical placebo group. We also constructed an historical active treatment group from the 5 mg daily arm of the VERT trials for comparison with the 5 mg daily and 35 mg once weekly treatment groups in the Once-a-Week study. Data were obtained from the risedronate 5 mg daily group (n=480) and 35 mg once-a-week group (n=485) in the Once-a-Week study and historical control groups representing daily placebo patients (n=114, matched from 993) and risedronate 5 mg daily patients (n=120; matched from 990) in the VERT studies. Patients received calcium supplementation (1000 mg daily); vitamin D was given if baseline serum 25-hydroxyvitamin D levels were low. Over 1 year, new vertebral fracture risk in the 35 mg once-a-week group was reduced by 77% relative to the historical placebo group (1.2% versus 5.0%; RR 0.23; 95% CI, 0.54 to 0.91, P=0.018), similar to the 1-year risk reduction observed in the VERT trials of risedronate 5 mg daily (61-65%). The incidence of new vertebral fractures in the three active treatment groups was similar: 1.7% in the historical risedronate 5 mg group, 1.5% in the risedronate 5 mg daily group from the Once-a-Week study, and 1.2% in the 35 mg once-a-week group. Risedronate 35 mg once a week appears as effective as the 5 mg daily dose in reducing the risk of new vertebral fractures in the first year of treatment. The use of appropriate historical control data provides an approach to the assessment of fracture effects in osteoporosis trials for which placebo-controlled data are not available.

[Trend of an osteoporosis curative medicine--Who uses what from when to when how?].

About the point of which medicine to use how in the medical treatment of osteoporosis, the large-scale clinical trial performed in Europe and America has been arranging. Especially, about calcium, vitamin D, estrogen, and bisphosphonates medicine can be used now based on the evidence about them. The necessity of medical treatment for the patient diagnosed as osteoporosis according to the criteria established by osteoporosis congress is guaranteed. However, when considering the necessity for prevention of osteoporosis, we would like to know the view about medicating osteopenia group, but there are few bases that for the moment it is important. Moreover, "up to when" in the point whether medical treatment is required, we have to wait for the report of the clinical test of medicine medication over a long period of time which is performed now. However, it is foundations to continue medicine medication as much as possible now, if effective. Although it became clear in estrogen medical treatment that a risk is higher than a benefit by medication examination over a long period of time, as well as this, It is necessary to discuss the benefit and the economic effect of an osteoporosis curative medicine.

Weekly oral bisphosphonates over 2 years prevent bone loss in cardiac transplant patients.

Heart transplantation (HTX) is an established therapy for end-stage heart disease. The aim of this study was to determine whether application of oral bisphosphonates is effective in preventing osseous complications after HTX. Thirty-three cardiac transplant recipients were treated with alendronate 70 mg/wk or risedronate 35 mg/wk in combination with 1000 mg calcium and 800 IU vitamin D. Markers of bone metabolism and dual-energy X-ray absorptiometry (DXA) were determined directly after HTX and 2 years later. Primary endpoints were changes in bone mineral density (BMD), markers of bone metabolism (osteocalcin, crosslaps), serum levels of the cytokines osteoprotegerin (OPG), receptor activator of NF kappa-B ligand (RANKL), and incidence of fractures. Eight patients presented with osteoporosis, and 16 patients with osteopenia by DXA without prevalent fractures. Over 2 years, the BMD improved in 2 patients from osteoporosis to osteopenia, and overall BMD remained stable, and fractures did not occur. In addition, the serum levels of OPG increased (P < .0005), and the RANKL levels (P < .001) as well as the RANKL/OPG-ratio decreased significantly (P < .0005). The serum crosslaps showed no significant changes. The BMD showed a significant association with the increased 25-vitamin D levels only in females (P < .001). In heart transplanted patients, weekly oral bisphosphonates in combination with calcium and vitamin D supplementation preserved bone mass, prevented uncoupling of bone resorption/formation and fractures. Bone density should be measured and adequately treated, that is, with regular bisphosphonates.

79-year-old post-menopausal woman with humerus fracture during teriparatide treatment.

The patient, a 79-year-old woman with a history of osteoporosis, presented with acute back pain without trauma, three years ago. Spinal X rays showed a vertebral compression fracture at T7, and DXA indicated a T-score of -2.65 BMD at the total hip. The patient started treatment with alendronate 70 mg once a week, plus calcium and vitamin D supplementation. After two years, she presented new acute back pain, and spinal X-rays revealed new vertebral compression fractures at T8 and T11. In September 2004, she stopped alendronate therapy and began teriparatide 20 microg subcutaneously each day for 18 months, associated with a dose of 1200 mg/day of calcium and 880 IU/day of vitamin D. In July 2005, she fell and sustained a fracture of the left proximal humerus. She was treated with conservative therapy and continued teriparatide therapy. After 25 days of conservative management, left shoulder X-ray showed quick formation of fracture healing. In conclusion, although teriparatide is indicated for the treatment of severe osteoporosis and not to enhance fracture healing, there are many experimental data which indicate that it may be beneficial also in enhancing fracture healing.

A randomized study of the effect of 5-year and lifetime hip fracture risk information on physician recommendations for management of low bone density.

Although risk prediction tools providing absolute fracture risk information are currently under development, little is known about US physicians' current thresholds for osteoporosis treatment or the potential effect of fracture risk information on treatment decisions. To investigate this, a random sample of US primary care physicians was surveyed. Treatment recommendations for 4 patient scenarios depicting postmenopausal women of varying ages, weights, and bone mineral density (BMD) were elicited. Physicians were randomly assigned to receive all scenarios with either a basic BMD report or an augmented BMD report containing 5-yr and lifetime absolute hip fracture risk estimates. Over 95% of physicians recommended prescription pharmacologic treatment of a 70-yr-old patient with osteoporosis. For 3 scenarios depicting women with T-scores of -1.01, treatment recommendations ranged from 30% to 44%. There were no statistically significant differences between physicians who received augmented and basic BMD reports, although those with augmented BMD reports were less likely to recommend prescription treatments. Physician specialty had inconsistent and small effects on recommendations. We conclude that nearly all of a random sample of US primary care physicians recommend pharmacologic treatment of osteoporosis, but a substantial minority also recommend treatment for patients who would not fit current guidelines. A BMD report including absolute hip fracture risk estimates did not change treatment recommendations.

Vitamin D

Bone health In general, no good evidence supports the commonly held belief that vitamin D supplements can help prevent osteoporosis. Its general use for prevention of this disease in those without vitamin D deficiency is thus likely not needed. For older people with osteoporosis, taking vitamin D with calcium may help prevent hip fractures, but it also slightly increases the risk of stomach and kidney problems. A study found that supplementation with 800 IU or more daily, in those older than 65 years was "somewhat favorable in the prevention of hip fracture and non-vertebral fracture". The effect is small or none for people living independently. Low serum vitamin D levels have been associated with falls, and low bone mineral density. Taking extra vitamin D, however, does not appear to change the risk.

Vitamin D deficiency in Australia

Infants, Children and Adults < 50 years: 5 μg/day (200 IU/day) Adults > 50 - < 70 years: 10 μg/day (400 IU/day) Adults > 70 years: 15 μg/day (600 IU/day) Treatment Day to day requirements of vitamin D are set around 800-1000IU to maintain healthy levels which in most cases can be provided by sun exposure. Increased amounts are required for individuals who are previously diagnosed as deficient. For those of moderate deficiencies, oral supplementation can be implemented into the diet at levels of 3000-5000 IU per day for a 6- to 12-week period continued by an ongoing reduced dose of 1000- 2000 IU per day to maintain stores in the body. Severe deficiency is treated through megadose therapy where patients are given doses around 100 000 IU to assist in raising stores faster to ensure physical health in restored to prevent further illness or disease. See also Vitamin D deficiency Vitamin D Sun exposure References Health in Australia Vitamin deficiencies

Clinical question: What is the best approach to managing glucocorticoid-induced osteoporosis?

Glucocorticoid-induced osteoporosis is common, and the resulting fractures cause significant morbidity and mortality. Rapid bone loss and increased fracture risk occur soon after the initiation of glucocorticoid therapy and are dose dependent. The increase in fracture risk is partly independent of bone mineral density, probably as a result of changes in bone material properties and increased risk of falling. Fracture risk can be assessed using the FRAX algorithm, although risk may be underestimated in patients taking higher doses of glucocorticoids. Because of the rapidity of bone loss and increase in fracture risk after the start of glucocorticoid therapy, primary prevention should be advised in high-risk individuals, for example older women and men, individuals with a previous fracture history and those with low bone mineral density. Bisphosphonates are the front-line choice for the prevention of fracture in the majority of glucocorticoid-treated patients, with teriparatide as a second-line option. Calcium and vitamin D supplements should be co-prescribed unless there is evidence of an adequate dietary calcium intake and vitamin D status.

Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis: 2001 update. American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis.

Glucocorticoid-induced bone loss should be prevented, and if present, should be treated (Table 2). Supplementation with calcium and vitamin D at a dosage of 800 IU/day, or an activated form of vitamin D (e.g., alfacalcidiol at 1 microg/day or calcitriol at 0.5 microg/day), should be offered to all patients receiving glucocorticoids, to restore normal calcium balance. This combination has been shown to maintain bone mass in patients receiving long-term low-to-medium-dose glucocorticoid therapy who have normal levels of gonadal hormones. However, while supplementation with calcium and vitamin D alone generally will not prevent bone loss in patients in whom medium-to-high-dose glucocorticoid therapy is being initiated, supplementation with calcium and an activated form of vitamin D will prevent bone loss. There are no data available to support any conclusion about the antifracture efficacy of the combination of calcium supplementation plus an activated form of vitamin D. Antiresorptive agents are effective in the treatment of glucocorticoid-induced bone loss. All of these agents either prevent bone loss or modestly increase lumbar spine bone mass and maintain hip bone mass. While there are no randomized controlled trials of prevention of glucocorticoid-induced bone loss or radiographic vertebral fracture outcomes with HRT or testosterone, patients receiving long-term glucocorticoid therapy who are hypogonadal should be offered HRT. The bisphosphonates are effective for both the prevention and the treatment of glucocorticoid-induced bone loss. Large studies have demonstrated that bisphosphonates also reduce the incidence of radiographic vertebral fractures in postmenopausal women with glucocorticoid-induced osteoporosis. Treatment with a bisphosphonate is recommended to prevent bone loss in all men and postmenopausal women in whom long-term glucocorticoid treatment at > or =5 mg/day is being initiated, as well as in men and postmenopausal women receiving long-term glucocorticoids in whom the BMD T-score at either the lumbar spine or the hip is below normal. While there is little information on the prevention or treatment of bone loss in premenopausal women, these women, too, may lose bone mass if they are being treated with glucocorticoids, so prevention of bone loss with antiresorptive agents should be considered. If bisphosphonate therapy is being considered for a premenopausal woman, she must be counseled regarding use of appropriate contraception. The therapies to prevent or treat glucocorticoid-induced bone loss should be continued as long as the patient is receiving glucocorticoids. Data from large studies of anabolic agents (e.g., PTH) and further studies of combination therapy in patients receiving glucocorticoids are eagerly awaited so additional options will be available for the prevention of this serious complication of glucocorticoid treatment.

[Adequacy of treatment for osteoporosis in primary prevention. Quantitative and qualitative study].

Quantitative study: To assess the prevalence of inadequacy of treatment for osteoporosis in primary prevention (OPP) in women aged 60-74years. Qualitative study: To evaluate the diagnostic and treatment criteria of the OPP and it's variability in primary care physicians (PC) and specialists. Quantitative study: observational, cross-sectional and retrospective study. women aged 60-74years with active treatment for OPP (n=424) in May 2012. Inadequacy if they had ≤2 risk factors with a DXA or DXA T-score ≥-2.4. Qualitative study: Delphi technique (15items) and two rounds of consultation. March-April 2014. PC physicians, rheumatologists and orthopaedic surgeons (n=251). Random sampling. Quantitative study: degree of inadequacy is 63.4%. In 43.2% isn't mention a diagnosis of osteoporosis. In 82.3% there isn't mention of risk factors. bisphosphonate 40.3% and calcium +vitaminD 47.9%. Qualitative study: 23% respond to the first round, and of these 67% the second round. Items with higher agreement were the important of the evaluation of risk factors for diagnosis and bisphosphonates for treatment. Items with fewer consensuses were using the FRAX and densitometry and treatment with only calcium +vitaminD. The percentage of inadequacy is high. The degree of registration in medical history is low. The Delphi method is useful for detecting discrepancies between recommendations of clinical practice guidelines and results.

The Good and the Bad About the 2017 American College of Physicians Osteoporosis Guidelines.

The American College of Physicians (ACP) published a set of guidelines on how to prevent fractures in men and women with low bone density or osteoporosis. As the population ages, the overall risk of fractures increases, thus burdening the health care system. These guidelines review current evidence for osteoporosis management, providing an update to the previous 2008 ACP's guidelines. The ACP put forth 6 recommendations addressing the complexities in osteoporosis management based on evidence available through October 2016 with a focus on bisphosphonates, calcium, vitamin D, and estrogen. Evidence was graded according to recommended strength by using the ACP standard methods. The ACP recommends anti-osteoporosis therapy with 1 of 3 bisphosphonates (alendronate, risedronate, or zoledronic acid) or denosumab in patients with osteoporosis, while excluding anabolic therapies, and recommends against raloxifene. Although bisphosphonates are the mainstay of treatment, anabolic therapy and raloxifene may be used in specific situations. Pharmacologic therapy is recommended for 5 years, oversimplifying length of therapy and failing to promote an individualized patient-centered care approach. Moreover, abrupt discontinuation of denosumab is associated with a decline in bone mineral density (BMD), which must be addressed. Routine monitoring of BMD by dual x-ray absorptiometry is not endorsed during treatment, which leads to underrecognition of management issues. Pharmacologic treatment with bisphosphonates for male osteoporosis is recommended, although therapies such as denosumab and teriparatide are excluded. Finally, the ACP recommends treatment for women aged ≥65 years at high risk for fracture with osteopenia after a discussion of patient preferences, fracture risk profile, and medications. Osteoporosis management is complex. The 2017 ACP guidelines address challenges faced by clinicians but oversimplify more complex issues. These are among a number of guidelines that are available for osteoporosis management, which may be used in combination with other sources to assist clinicians with diagnostic and management strategies.

Impact of an osteoporosis specialized unit on bone health in breast cancer survivals treated with aromatase inhibitors.

Considering the increased fracture risk in early breast cancer patients treated with aromatase inhibitors (AI), we assessed the impact of a preventive intervention conducted by a specialized osteoporosis unit on bone health at AI treatment start. Retrospective cohort of postmenopausal women who started treatment with AI after breast cancer surgical/chemotherapy treatment and were referred to the osteoporosis unit for a comprehensive assessment of bone health. Bone densitometry and fracture screening by plain X-ray were performed at the baseline visit and once a year for 5 years. The final record included 130 patients. At AI treatment start, 49% had at least one high-risk factor for fractures, 55% had osteopenia, and 39% osteoporosis. Based on the baseline assessment, 79% of patients initiated treatment with bisphosphonates, 88% with calcium, and 79% with vitamin D. After a median of 65 (50-77) months, 4% developed osteopenia or osteoporosis, and 14% improved their densitometric diagnosis. Fifteen fractures were recorded in 11 (8.5%) patients, all of them receiving preventive treatment (10 with bisphosphonates). During the follow-up period, patients with one or more high-risk factors for fracture showed a greater frequency of fractures (15% vs. 3%) and experienced the first fracture earlier than those without high-risk factors (mean of 99 and 102 months, respectively; P=0.023). The preventive intervention of a specialized unit at the start of AI treatment in breast cancer survivors allows the identification of patients with high fracture risk and may contribute to preventing bone events in these patients.

An update on glucocorticoid-induced osteoporosis.

In general, bone loss from glucocorticoid treatment occurs rapidly within the first 6 months of therapy. Glucocorticoids alter bone metabolism by multiple pathways; however, the bone loss is greatest in areas rich in trabecular bone. Preventive measures should be initiated early. It is the author's opinion that all subjects initiating treatment with prednisone at 7.5 mg or greater require calcium supplementation (diet plus supplement) at a dose of 1500 mg and vitamin D at a dose of 400 to 800 IU/d. If the patient is going to remain on this dose of glucocorticoid for more than 4 weeks, an antiresorptive agent should be started (e.g., estrogen, bisphosphonate, raloxifene). If a patient has established osteoporosis and is either initiating glucocorticoid therapy or is chronically treated with prednisone at 5 mg d or greater in addition to calcium and vitamin D supplementation, a potent antiresorptive agent (bisphosphonate) should be started. A bone mineral density measurement of either the lumbar spine or the hip may be helpful is assessing an individual's risk of osteoporosis, may improve compliance with treatment, and can be used to monitor the efficacy of the prescribed therapy. There is no reason to withhold treatment for glucocorticoid-induced bone loss until a bone mass measurement is taken, however. In motivated patients, a weight-bearing and resistance exercise program should be prescribed to help retain muscle strength and prevent depression. If hypercalciuria develops with glucocorticoid use, either thiazide diuretics or sodium restriction may be helpful. In patients who continue to lose bone or experience fracture's despite antiresorptive therapy while on glucocorticoids, bone-building anabolic agents (e.g., hPTH 1-34 or PTH 1-84) may be available someday soon.