To enhance state-of-the-art knowledge and expert care for osteoporosis and other metabolic bone disorders in Lebanon through education, research and service. To join OSTEOS please visit our website on: http://www.osteos.org.lb For your suggestions, please contact us: osteos@osteos.org.lb

Welcome note

Dear colleagues,

The spring issue of the OSTEOS newsletter is out. A new look and a bouquet of varied exciting topics brought to you wherever you are.

OSTOES newsletter aims to evolve the inter-active collaboration between the contribu-tors and the readers in various specialties, in addition to bringing essential information to the public. Many of the topics reviewed and published in the newsletter are intended to draw our clinical curiosity to recent updates, refresh and better our clinical skills, as well as engage the patients and the public in health education and promotion. All of us should play a role in patient’s health aware-ness and health education by reminding them that their bone is among their pre-cious assets. We should teach them how they can invest in it, protect it and work to make it the strongest that it can be. Let’s

encourage them to take the advantage of every occasion to adopt healthy habits that will benefit their bones years down the road. Evidence is mounting on how lifestyle habits and positive modifications, including optimal nutrition, exercise, ade-quate vitamin intake, and avoiding bad habits can boost the skeletal system and strengthen our bones. Summer is still here, so let us all advise patients and pub-lic alike on suitable appropriate sun expo-sure.

Wishing you and our patients an enjoya-ble relaxing family fun summer!!

Faysal El- Kak, MD, MS President, OSTEOS

Editor-in-Chief: Asma Arabi, M.D, MSc Guest Editors: Mirella Hage, MD & Marlène Chakhtoura,MD

President Faysal El-Kak, MD

Founding President Ghada El-Hajj Fuleihan, MD, MPH

Vice-President Georges Halaby, MD

Treasurer Jad Okais, MD

Executive Committee Rafic Baddoura, MD, MPH Ghada El-Hajj Fuleihan, MD, MPH Jad Okais, MD Muhieddine Seoud, MD

Non Voting Members Assaad Mohanna, MD Walid Saghir, MD Imad Uthman, MD

Newsletter of the Lebanese Society for Osteoporosis and Metabolic Bone Disorders

S p r i n g I s s u e , 2 0 1 3

OSTEOS NEWSLETTER

M i s s i o n o f

O S T E O S R e a d i n t h i s i s s u e

Calcium Supplements & Reduced Mortality in Women.

Safe Target Range for Serum Calcidiol.

Vitamin D Levels & Incident Type 2 Diabetes.

Updates on teriparatide.

Antiresorptive Therapies & Glucose Metabolism.

Tricyclic Antidepressant and Risk of Fractures.

Predicting Need for Fixation of Atypical Femoral Fracture.

Layout & Design by Sarine El Daouk

Vertebral Augmentation versus conserva-tive treatment for vertebral fractures.

Hormone therapy for preventing cardio vascular disease in post-menopausal women.

Calcium and Vitamin D Boost HRT Effect on Hip Fracture Risk.

New concerns with antiosteoporotic drugs.

Densitometry corner

Upcoming meetings

Executive Board

The health risks and benefits from calcium and vitamin D intake are still uncertain. Both low and high 25 (OH) D levels have

been associated with increased mortality. Similarly, calcium supplementation has been associated with both beneficial and

detrimental cardiovascular effects. This association was studied in a prospective cohort study with a 10 year follow up

*the Canadian Multicenter Osteoporosis Study: CaMos+. 9033 men and women with non missing datas on calcium and

vitamin D intake were included. Overall, 7.3% and 15.2% of men and women respectively were on calcium supplements

alone. 4.4% of men and 3.7% of women were on vitamin D supplements alone .15.4% of men and 29% of women were using

both calcium and vitamin D supplements. There were 1160 deaths within the study period. Among women, per 500mg

increase in total daily calcium intake, there was a trend for benefit with a HR of 0.95 (95% CI, 0.89-1.01). However, the use of

calcium supplements was associated with a reduced mortality (HR=0.78; 95% CI, 0.66-0.92) in women but not in men with

no dose-response effect reported among users. Furthermore, the association was attenuated with increased dosage and

remained significant only for those with a daily supplement dose <1000mg. In men, there were no definitive associations

between calcium intake and mortality. Similarly, the associations between vitamin D intake and mortality in both men and

women were inconclusive. The authors still recommended “assessing dietary intake to meet calcium and vitamin D require-

ments for bone health and to consider supplementation necessary to meet the requirements”. Langsetmo et al, J Clin En-

docrin Metab. Epub ahead of print

In a large population-based cohort of 1,282,822 aged more than 45 years, Dror et al identified 422,822 individuals tested for vitamin D. Among the study population, 30% had serum 25(OH) D levels <10ng/ml, 32% <20ng/ml, 35% between 20 and 36% and 3% >36ng/ml. During the 54-month study period, 12,280 died of any cause (905 with acute coronary syndrome) and 3933 were diagnosed with acute coronary syndrome. A U-shaped relation between serum 25(OH) D and mortality or acute coronary syndrome was found. Compared to individuals with levels of calcidiol of 20-36ng/ml, the adjusted HR of those with levels <10, between 10 and 20, >36 were 1.88 (CI: 1.80–1.96), 1.25 (CI: 1.21–1.30), and 1.13 (CI: 1.04–1.22) (P < 0.05), respectively. Therefore, a safe range of serum calcidiol of 20-36ng/ml was identified beyond which an increased mortality or cardiovascular risk was seen. However, the small number of patients with calcidiol levels > 36ng/ml (3%) limited any further analysis of this group. The authors finally suggested a conservative approach regarding vitamin D supplementation and recommended to tailor the amount of supplementation according to individual needs and to serm calcidiol levels. Dror et al, J Clin Endocrin Metab. Epub ahead of print

C a l c i u m S u p p l e m e n t s L i n k e d t o a R e d u c e d M o r t a l i t y i n W o m e n .

A S a f e T a r g e t R a n g e f o r S e r u m C a l c i d i o l I d e n t i f i e d .

Page 2 O S T E O S N E W S L E T T E R

In a paper recently published in Diabetes Care, Song et al conducted a meta-analysis to study the association between blood 25-hydroxy vitamin D *25(OH)D+ levels and incident risk of type 2 diabetes *DM2+. The authors conducted a systematic search of the MEDLINE and Embase databases and a hand search of references from original reports up to 31 October 2012 where all prospective observational studies that assessed the association between blood levels of 25(OH)D and risk of incident DM2 and that were identified by the search methodology were included. Overall, a total of 21 prospective studies involving 76,220 participants and 4,996 incident DM2 cases were included. Higher 25(OH)D levels were associated with a lower risk of DM2. This inverse association did not differ by sex, duration of follow-up, study sample size, diabetes diagnostic criteria, or 25(OH)D assay method. Each 10 nmol/L *2.5 ng/ml+ increment in 25(OH)D levels was associated with a 4% lower risk of DM2 (95% CI 3-6). Song et al, Diabetes Care 2013;36:1422-8.

2 5 - H y d r o x y V i t a m i n D L e v e l s a n d I n c i d e n t T y p e 2

D i a b e t e s : M e t a a n a l y s i s o f p r o s p e c t i v e s t u d i e s .

Page 3 S p r i n g I s s u e , 2 0 1 3

Combining anti-osteoporosis drugs has not been shown so far to confer any additional benefit to monotherapy. Tsai el

al recently evaluated the combination of the anabolic agent teriparatide and the RANKL inhibitor denosumab on bone

density compared to either agent alone in a randomized open label 12 months study including 94 postmenopausal > 45

years of age, at high risk of fracture. Patients received 20 mcg teriparatide daily (n=31), 60 mg denosumab every 6

months (n=33) or a combination of the two treatments (n=30). After 12 months, lumbar spine (LS) BMD increased

more in the combination group (9.1%) compared with the teriparatide (6.2%, p=0.01) or denosumab group (5.5%,

P=0.0005). Femoral neck (FN) and total hip (TH) BMD increase were also greater in the combination group vs. teripar-

atide and denosumab alone. In terms of biochemical markers, the denosumab group showed a greater suppression of

the bone formation marker osteocalcin and a similar supper sion of the bone formation marker PINP compared to that

of the combination group. A similar suppression of the bone resoprtion marker CTX was observed with combining teri-

paratide and denosumab monotherapy. In conclusion, combining teriparatide and denosumab resulted in a greater

increase in BMD at the LS, TH 7 FN in post menopausal women at high risk of fracture than either drug alone. The au-

thors commented “Perhaps, unlike bisphosphonate combinations, the combination of teriparatide and denosumab

permits continued teriparatide-induced modelling-based bone formation, as has been documented in some studies of

teriparatide monotherapy”. Tsai JN. Lancet. 2013;140:60856-9.

The EuroGIOPs trial, a randomized open label active comparator controlled study, included men who had taken glucocorticoids for ≥3 months and had an areal BMD T-score of ≤-1.5 standard deviations. Ninety two men with a mean age of 56.3 years were randomized to receive either teriparatide 20 mcg per day (n=45) or risedronate 35 mg per week (n=47) and 1 g calcium and 1,200 IU vitamin D daily for 18 months. Median glucocorticoid dose was 8.8mg/day and glucocorticoids were taken for a median duration of 6.4 years. Among the participants, 36 patients (39.1%) had a previous fracture and 30 patients (32.6%) had previously received bisphosphonate therapy. At 18 months, both teriparatide and risedronate significantly increased lumbar spine trabecular BMD measured by QCT with greater increases seen in the teriparatide group (16.3% ± 4.2% vs. 3.8% ± 4.1%; P=0.004). In addition, HRQCT trabecular and cortical variables were also significantly increased in both treatment groups with larger increases reported with teriparatide in integral and trabecular BMD and in bone surface to volume ratio (BS/BV) as microstructural variable. Similarly, significant increments in estimated vertebral strength were also reported in both groups (teriparatide: 26%-34% vs. risedronate: 4.2%- 6.7%; P<.005) after 18 months, with however larger improvements seen in the teriparatide group for all loading modes (0.005 < p < 0.015). Intriguingly, five patients on risedronate developed new clinical fractures during 18 months and none on teriparatide with a trend in favor of teriparatide (P =0.05). In conclusion, in this trial, teriparatide was associated with greater improvements in BMD, bone strength and microstructure than risedronate in men with GIOP. Glüer et al, J Bone Miner Res. 2013;28:1355-68

T e r i p a r a t i d e i n C o m b i n a t i o n w i t h D e n o s u m a b S u p e r i o r t o M o n o t h e r a p y

f o r B o n e D e n s i t y .

T e r i p a r a t i d e S u p e r i o r t o R i s e d r o n a t e i n M e n w i t h G l u c o c o r t i c o i d -

I n d u c e d O s t e o p o r o s i s ( G I O P ) .

Page 4 O S T E O S N E W S L E T T E R

Undercarboxylated osteocalcin (ucOC) has been shown to act as a hormone that promotes insulin sensitivity in peripheral tissues and insulin secretion by the pancreas in rodent models. Consequently, the reduction of OC level with antiresorptive therapies could lead to insulin resistance and increased risk of diabetes. Randomized placebo-controlled trials of antiresorptive therapies provide an optimal setting to determine whether reductions in bone turnover affect glucose metabolism. Three trials were considered to evaluate this effect: Fracture Intervention Trial (FIT) of alendronate (4 years), Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly Pivotal Fracture Trial (HORIZON-PFT) (3 years), and Fracture Reduction Evaluation of Denosumab in Osteoporosis Every 6 months (FREEDOM) trial (3 years). Post hoc analyses of these trials assessed the effect of each intervention on fasting glucose, weight gain and diabetes incidence. At the end of the trials, there was no significant difference in fasting glucose level between treatment and placebo. Only Alendronate and Denosumab were associated with significant, but small, weight gain compared to placebo (0.32 kg, p=0.003 and 0.31 kg, p=0.023 respectively). Diabetes incidence was not increased in any of the three trials. In an unadjusted pooled estimate, the odds ratio for incident diabetes was 0.90 (95% CI 0.74–1.10). Results did not change in the subgroup of women who were overweight and obese. Schwartz AV et al J Bone Miner Res. 2013;28:1348-54.

E f f e c t s o f A n t i r e s o r p t i v e T h e r a p i e s o n G l u c o s e

T r i c y c l i c A n t i d e p r e s s a n t U s e a n d R i s k o f F r a c t u r e s : A M e t a - A n a l y s i s

Depression is associated with low bone density and increased risk of fracture. Tricyclic

antidepressants (TCA), widely used for depression, through their anticholinergic effects, could

increase the risk of falls leading to fractures. The aim of this meta-analysis was to

quantitatively assess all qualified studies that have examined the effect of TCAs on fracture

risk. Twelve studies (5 cohorts & 7 case-control) met the inclusion criteria. TCA use was

associated with a significantly increased risk of fracture (RR 1.4; 95% CI: 1.3–1.6), inde-

pendently of depression and BMD; with a higher risk in duration of exposure < 6 weeks com-

pared to >6 weeks exposure and in current users compared to former users. TCAs should be

monitored for fracture risk, especially during the initial period of treatment. Wu Q et al J

Bone Miner Res. 2013;28(4):753-63

Idiopathic osteoporosis (IOP) is an uncommon disorder that affects young otherwise healthy individuals and results in low-trauma fractures. Cohen et al evaluated the effect of 20µg teriparatide daily for 18-24 months on BMD and microarchitecture in 21 premenopausal women (mean age of 39.6 years), with unexplained fragility fracture or low BMD. A significant increase in spine (10.8±8.3%), hip (6.2±5.6%), and femoral neck BMD (7.6±3.4%) was reported. Similarly, the formation marker serum N-terminal propeptide of procollagen type 1 and the resorption marker C-telopeptide significantly increased, peaking at 150% and 75% above baseline at 6 months respectively and returning to baseline by 18-24 months. Transiliac biopsies showed increments in cortical width, trabecular bone volume, number and stiffness and decrements in trabecular separation. Participants with no increase in BMD (N=4) had lower baseline bone formation rate, higher IGF-1, and a blunted, delayed rise in P1NP suggesting a defective osteoblast response to IGF-1 and PTH. Therefore, teriparatide improved BMD as well as trabecular microarchitecture and stiffness in the majority of premenopausal women with IOP. Cohen et al, J Clin Endocrinol Metab 2013;98:1971–1981.

T e r i p a r a t i d e I m p r o v e d B o n e D e n s i t y a n d

M i c r o a r c h i t e c t u r e i n P r e m e n o p a u s a l W o m e n

Page 5 S p r i n g I s s u e , 2 0 1 3

A typical femoral fractures have been emerging recently as a complication of long term bisphosphonate use. This retrospective study aimed at evaluating the clinical results of incomplete atypical femoral fractures and determining factors associated with requirement of fixation in incomplete atypical femoral fracture. Medical records of 65 incomplete femoral fractures in 51 patients were reviewed.14 patients had bilateral involvement. Patients were treated conservatively with limited weight bearing using an assistive device. 19 patients used teriparatide for a mean of 4.6 months. Internal fixation was indicated in case of complete fracture or intractable pain at weight bearing. Results of the study show that two thirds of patients had a history of bisphosphonate use prior to diagnosis of atypical femoral fracture, for more than 4 years. 47.7% of hips required internal fixation during a mean follow up of 9.4 months. Subtrochanteric involvement was the only characteristic significantly associated with requirement of fixation (HR 2.7; 95% CI: 1.189 – 6.189). Age, gender, BMI, duration otreatment, T-score of total femur, BMD, osteocalcin, and use of teriparatide did not predict the need for internal fixation. Teriparatide, considered one of the treatment options of atypical femoral frac-tures, did not completely prevent the need of internal fixation since 7 out of 12 patients who were prescribed teriparatide required surgery. Lee YK et al J Clin Endocrinol Metab. 2013, Epub ahead of print

P r e d i c t i n g N e e d f o r F i x a t i o n o f A t y p i c a l F e m o r a l F r a c t u r e

V e r t e b r a l A u g m e n t a t i o n C o m p a r e d W i t h C o n s e r v a t i v e T r e a t m e n t

f o r O s t e o p o r o t i c S p i n a l F r a c t u r e s .

Vertebroplasty and kyphoplasty can be used for the treatment of painful vertebral fractures.

Given the conflicting results of randomized controlled trials that assessed their effectiveness,

compared to sham procedure or medical pain treatment , Anderson et al compared the effect

of cement augmentation versus conservative management on pain relief , functional

improvement, and quality of life at early (<12weeks ) and late (>26 weeks) time point, in a meta

-analyses of six studies. Results showed a beneficial effect of vertebroplasy on pain visual

analog scale for both time points (p<0.001). Similarly, functional recovery and health-related

quality of life favored vertebroplasty. As for medical adverse events, there was no statistically

significant difference in their occurrence between the two groups, even when considering

secondary fractures. Anderson PA et al J Bone Miner Res. 2013 ;28:372-82.

C a l c i u m a n d V i t a m i n D B o o s t H R T E f f e c t o n H i p

The literature about supplemental calcium and vitamin D to prevent fractures and using

postmenopausal HRT to treat osteoporosis are controversial. In a recent study, Robbins et

al tested the added value of calcium and vitamin D (CaD) in fracture prevention in 16,089

women taking postmenopausal hormone therapy (HT) in a prospective, partial-factorial,

randomized, controlled, double-blind trial among Women's Health Initiative postmenopau-

sal participants aged 50 to 79 years with a mean follow-up of 7.2 years. There was an inter-

action between HT and CaD on hip fracture (P interaction = 0.01). The effect of CaD was

stronger among women assigned to HT (HR 0.59; 95% CI, 0.38-0.93) than among women

assigned to placebo (HR 1.20; 95% CI, 0.85-1.69). CaD supplementation enhanced the anti-

fracture effect of HT: the effect of HT on hip fracture was stronger among women assigned

to active CaD (HR 0.43; 95% CI, 0.28-0.66) than among women assigned to placebo (HR

0.87; 95% CI, 0.60-1.26). There was no interaction between HT and CaD on change in hip or

spine bone mineral density. The authors concluded that postmenopausal women at normal

risk for hip fracture who are on CaD supplementation experience significantly reduced inci-

dent hip fractures beyond HT alone at all levels of personal baseline total calcium intake.

Robbins et al, Menopause, 2013 Epub ahead of print

“Evidence from systematic reviews of observational studies suggests that hormone replacement therapy (HT) may have beneficial effects in reducing the incidence of cardiovascular disease (CVD) events in post-menopausal women. This is an updated version of a Cochrane review first published in 2005 (Gabriel-Sanchez 2005). Objectives: To assess the effects of HT for the prevention of CVD in post-menopausal women, and whether there are differential effects between use of single therapy alone compared to combination HT and use in primary or secondary prevention. Search methods: We searched the following databases to April 2010: Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE, EMBASE and LILACS. Selection criteria: Randomised controlled trials (RCTs) of women comparing orally administered HT with placebo with a minimum of six-months follow-up. Data collection and analysis: Two authors independently assessed study quality and extracted data. Risk Ratios (RR) with 95% confidence intervals were calculated for each outcome. Results were combined using fixed-effect meta-analyses, and where possible, further stratified analyses conducted to assess the effect of time on treatment. Addition-ally, univariate meta-regression analyses were undertaken to assess whether length of trial follow-up, single or combi-nation treatment, or whether treatment for primary or secondary prevention were potential predictors for a number of CVD outcomes in the trials. Main results: Four new trials were identified through the update; one trial included in the previous review was excluded. Therefore the review included 13 trials with a total of 38,171 post-menopausal women. Overall, single and combination HT in both primary and secondary prevention conferred no protective effects for all cause mortality, CVD death, non-fatal MI, or angina. There were no significant differences in the number of coronary artery by-pass procedures or angioplasties performed between the trial arms. However there was an in-creased risk of stroke for both primary and secondary prevention when combination and single HT was combined, RR 1.26 (95% CI 1.11 to 1.43), in venous thromboembolic events, RR 1.89 (95% CI 1.58 to 2.26) and in pulmonary embolism RR 1.84 (95% CI 1.42 to 2.37) relative to placebo. The associated numbers needed-to-harm (NNH) were 164, 109 and 243 for stroke, venous thromboembolism and pulmonary embolism respectively. Authors’ conclusions: Treatment with HT in post-menopausal women for either primary or secondary prevention of CVD events is not effective, and causes an increase in the risk of stroke, and venous thromboembolic events. HT should therefore only be considered for women seeking relief from menopausal symptoms. Short-term HT treatment should be at the lowest effective dose, and used with caution in women with predisposing risk factors for CVD events”. Main C et al Cochrane Database Syst Rev. 2013 (copied verbatim)

H o r m o n e t h e r a p y f o r p r e v e n t i n g c a r d i o v a s c u l a r d i s e a s e i n p o s t -

m e n o p a u s a l w o m e n .

Page 6 O S T E O S N E W S L E T T E R

Page 7 S p r i n g I s s u e , 2 0 1 3

The European Medicine Agency (EMA) recommended restrictions in the use of Strontium Ranelate due to

concerns of adverse cardiovascular events in users. In a routine benefit-risk assessment of clinical studies

including around 7500 postmenopausal women with osteoporosis, an increased risk for adverse cardiac events were

noted with strontium ranelate as compared with placebo (1.7% versus 1.1 %), with a relative risk of 1.6

(95% confidence interval, 1.07 to 2.38). The Committee for Medicinal Products for Human Use (CHMP) also

commented that there was an imbalance in the number of serious cardiac events with the drug seen in two other

studies, one in men with osteoporosis and the other in patients with osteoarthritis. Therefore, the following

restrictions in the use of strontium ranelate were issued by the EMA:

Protelos should only be used for the treatment of severe osteoporosis in postmenopausal women at high risk of

fracture and severe osteoporosis in men at increased risk of fracture.

Protelos is contraindicated in patients with a current or past history of ischaemic heart disease, peripheral arterial

disease, or CVD, or in patients with uncontrolled hypertension.

Protelos should only be started by a physician experienced in the treatment of osteoporosis.

Physicians should base their decisions to prescribe Protelos / Osseor on an assessment of the individual

patient’s risks. The patient’s risk of developing cardiovascular disease should be evaluated before and at

regular intervals during treatment.

Treatment should be stopped if the patient develops ischaemic heart disease, peripheral arterial disease or

cerebrovascular disease or if hypertension becomes uncontrolled”.

Recommendation to restrict the use of Protelos/Osseor (strontium ranelate) EMA/258269/2013

S t r o n t i u m R a n e l a t e L i n k e d t o A d v e r s e C a r d i a c E v e n t s

C a l c i t o n i n L i n k e d t o C a n c e r R i s k .

The FDA’s Advisory Committee for Reproductive Health Drugs and the Drug Safety and Risk Management

Advisory Committee voted that calcitonin salmon nasal spray should no longer be used for the treatment of

postmenopausal osteoporosis due to concerns of possible cancer risk. Following the concern of prostate cancer risk

arising from the osteoarthritis trials, Novartis conducted trial-level meta-analyses to evaluate the potential malignancy

risk associated with calcitonin salmon. In both Novartis’s and FDA’s analyses, a higher risk of malignancy was suggested

in nasal spray calcitonin treated patients compared to those treated with placebo; specifically OR=1.6, 95% CI (1.1, 2.3)

and risk difference =1.6%, 95% CI (0.5, 2.8). In the nasal spray and oral formulation trials, results also suggested a high-

er risk of malignancy for patients treated with calcitonin compared to those treated with placebo; specifically OR=1.4,

95% CI (1.1, 1.7) and risk difference=1.0%, 95% CI (0.3, 1.7). However, the FDA commented that these results were

heavily influenced by the largest and only long-term nasal spray trial of 5 years duration in which the largest

number of malignancies occurred. Earlier in 2012, the European Medicines Agency (EMA) recommended withdrawal of

calcitonin nasal spray because of increased risk of cancer and restricted the use of calcitonin to short term basis for the

treatment of Paget's disease, acute bone loss resulting from sudden immobilization, and hypercalcemia caused by

cancer. The Committee for Medicinal Products for Human Use (CHMP) determined a higher risk of developing cancer

ranging from 0.7% with oral formulations to 2.4% for the nasal formulation in calcitonin users vs. those who took

placebo. Although the cancer signal is weak at this point, the FDA concluded: “The potential for a cancer risk with

calcitonin salmon therapy cannot be ignored.”

Briefing Information for the March 5, 2013, Joint Meeting of the Advisory Committee for Reproductive Health Drugs and the Drug Safety and Risk Management Advisory Committee.

Questions and answers on the review of calcitonin-containing medicines EMA/731082/2012

D e n s i t o m e t r y c o r n e r

Page 8 O S T E O S N E W S L E T T E R

Ms A.Z a 70 year old lady came to your clinic with two BMD scans done at 4 months interval. The first BMD was

measured 4 months ago. She was then reassured and told that her BMD was normal (total hip BMD 1.081,

T-Score total hip -0.1) *figure 1+. However, 4 months later, she sustained a fracture of the humeral head after a fall

from her own height. Plain X-ray showed marked osteopenia so another BMD was requested and showed osteoporosis

(total hip BMD 0.756, T-Score total hip -2.9). The patient is concerned about the rapid deterioration in her BMD.

She denies the intake of steroids or of any other drug that could affect bone mass. After examining the scans, what can

you tell the patient about it?

A. Your bone density dropped markedly and we should do an extensive work up to loo4k for the cause

B. Your bone density dropped because you are not taking any calcium supplements.

C. Your bone density dropped markedly and you should start Forteo to prevent further loss and fracture.

D. Reassure her because the second BMD was not adequately analyzed.

E. You do have osteoporosis but an external artifact falsely increased BMD in the first set of scans.

F. The difference in BMD is because the scans were obtained on two different machines.

Date Event Place

28-30 Sep 2013 3rd Abu Dhabi Advanced Rheumatology

Review Course (ADARRC).

Abu Dhabi, United Arab

Emirates

U p c o m i n g M e e t i n g s

4-7 Oct 2013 35th annual meeting of the American

Society for Bone and Mineral Research

(ASBMR)

Baltimore, Maryland, USA

26-30 Oct 2013 ACR/ARHP Annual Meeting San Diego, California, USA

14-15 Nov 2013 IOF Osteoporosis Update Dubai, United Arab Emirates

14-16 Nov 2013 Annual meeting of the Lebanese Society

of Obstetrics & Gynecology

Movempick Hotel, Beirut

1-3 Dec 2013 26e congrès français de rhumatologie La Defense, Paris France

5-6 Dec 2013 5th annual meeting of the OSTEOS Gefinor Rotana, Beirut

24-25 Jan 2014 ISCD Osteoporosis Academy Course Gefinor Rotana-Beirut

dHints: When interpreting BMD scans, I

C o r r e c t a n s w e r d e n s i t o m e t r y c o r n e r : E

Hints: When interpreting BMD scans, it is very important to check for the presence of any artifact *internal or external+ that could falsely increase bone mass.

Examples of internal artifacts include osteoarthritis, osteophytes, surgical clips, aortic

calcifications, contrast media, and calcium tablet. Example of external artifacts include

navel rings, metal from zipper, coin, clip, or other metallic object……..etc. in this case the

artifact was due to a coin in the patient’s pocket!!

Figure 1

Figure 2