USPSTF: Vitamin D, calcium supplements don't prevent fx

For non-institutionalized postmenopausal women, the U.S. Preventive Services Task Force recommends against daily supplementation with ≤400 IU of vitamin D₃ and ≤1,000 mg of calcium for primary prevention of fractures, and a lack of evidence impairs the provision of recommendations for other populations, according to a statement published online Feb. 26 in the Annals of Internal Medicine.

27 feb 2013—For non-institutionalized postmenopausal women, the U.S. Preventive Services Task Force (USPSTF) recommends against daily supplementation with ≤400 IU of vitamin D₃ and ≤1,000 mg of calcium for primary prevention of fractures, and a lack of evidence impairs the provision of recommendations for other populations, according to a statement published online Feb. 26 in the Annals of Internal Medicine.

Using data from two systematic evidence reviews and a meta-analysis, Virginia A. Moye, M.D., M.P.H., and colleagues on behalf of the USPSTF in Rockville, Md., examined the effects of vitamin D supplementation, with or without calcium, on bone health outcomes in community-dwelling adults. Adverse effects of supplementation were also considered.

The USPSTF found that, regarding premenopausal women and men, the current evidence was insufficient to support an evaluation of the benefits and harms of combined vitamin D and calcium supplementation on the primary prevention of fractures. For non-institutionalized postmenopausal women, insufficient evidence was available to examine the balance of benefits and harms for supplementation with >400 IU of vitamin D₃ and >1,000 mg of calcium for primary prevention of fractures. For non-institutionalized postmenopausal women, the USPSTF recommends against daily supplementation with ≤400 IU of vitamin D₃ and ≤1,000 mg of calcium.

"While we wait for the results of further research, the USPSTF's cautious, evidence-based advice should encourage clinicians to think carefully before advising calcium and vitamin D supplementation for healthy individuals," write the authors of an accompanying editorial.

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Opiate painkillers raise fracture risk

NEW YORK, 29 jan 2010– Older adults who take powerful prescription painkillers known as opioids face an increased risk of bone fractures, especially at moderately high medication doses, a new study finds.

Opioids are powerful narcotic pain medications that include morphine, oxycodone (Oxycontin and other brands) and hydrocodone (Vicodin and others).

The drugs work well against severe pain in the short term, but their longer-term effectiveness for chronic pain is less clear. Moreover, with longer use comes the risk of addiction, in addition to side effects such as nausea, constipation, dizziness and sedation.

That dizziness and sedation can also set opioid users up for falls, which, in older people especially, may result in serious fractures.

The new study, published in the Journal of General Internal Medicine, confirms the risk of fracture associated with opioids, and also shows that moderately higher drug doses further the hazard.

Researchers found that among more than 2,300 older adults with chronic pain, the risk of suffering a bone fracture was higher when patients were using an opioid for a prolonged period than when they were opioid- free.

The individuals in the study were 60 years of age or older. None of the patients was suffering from cancer-related pain. (Guidelines for treating severe cancer pain are often different than guidelines for non-cancer pain.)

The annual rate of fractures among study participants who were not currently using opioids was just under 4 percent, while current users showed a fracture rate of 6 percent. And among patients currently taking opioid doses of at least 50 milligrams per day, the annual fracture rate was 10 percent.

According to the researchers, 50 milligrams is considered to be in the moderate range for opioid doses.

"Some of these fractures were significant," said senior researcher Dr.

Michael Von Korff, of the Group Health Research Institute in Seattle.

In an interview, he noted that 37 percent of fracture victims ended up in the hospital and nearly one-quarter entered a nursing home within one month of the accident.

The findings come at a time when long-term opioid use for non-cancer- related pain is coming under increased scrutiny.

About 8 million Americans are using opioids to control chronic pain, Von Korff said, yet the long-term effectiveness of the drugs is uncertain, and may vary widely from person to person. Some people find relief, while others find their pain actually worsens, Von Korff noted.

A report published in October by the Cochrane Collaboration, an international medical research organization, concluded that for older adults with osteoarthritis, the risks of long-term opioids may outweigh the modest pain relief.

And in a separate study published this week in the Annals of Internal Medicine, Von Korff's team highlights the potential for overdose among people with legitimate prescriptions.

The researchers found that among 10,000 patients on opioids for at least three months, 51 suffered at least one overdose, with fatal results for six. As in this latest study, higher medication doses conferred a greater risk.

The bottom line, Von Korff said, is that "these drugs need to be taken cautiously and under close medical supervision."

The current study included 2,341 older adults who, at some point between 2000 and 2005, were prescribed opioids for at least 90 days -- most commonly for chronic back pain, osteoarthritis or pain in the extremities.

To limit the risks of falls and other side effects, Von Korff said that patients on opioids should work with a single physician who is aware of all the medications they are taking. That will help avoid any potentially hazardous drug interactions.

And given the importance of dosage, Von Korff said, "never use more medication than your doctor has prescribed."

He also advised opioid users who feel overly sedated or have had dizziness or falls to tell their doctors about it.

SOURCE: Journal of General Internal Medicine, online January 5, 2010.

Prolonged Use of Loop Diuretics May Raise Fracture Risk

Medications are normally used by women already at risk for fractures

30 jan 2009-- Postmenopausal women who use loop diuretics are at increased risk of fractures, according to a report published in the Jan. 26 issue of the Archives of Internal Medicine.

Laura D. Carbone, M.D., of the University of Tennessee Health Science Center in Memphis, and colleagues conducted a study using data from the Women's Health Initiative on 133,855 women, of whom 3,411 used loop diuretics and 130,444 did not. They looked at the women's risk of falls and fractures over a mean period of 7.7 years and analyzed data on baseline and three-year bone mineral density for 300 users and 9,124 non-users of loop diuretics.

Women who had ever used loop diuretics were not at significantly increased risk of total, hip and clinical vertebral fractures and falls, the data revealed. However, those who used loop diuretics for more than three years had a 16 percent higher risk of both clinical and total fractures, compared with non-users, the researchers report. There was no association between changes in bone mineral density and use of loop diuretics, the investigators found.

"The relationship of falls to medication use is complex. We hypothesized that loop diuretics might be positively associated with falls because they may cause orthostatic hypotension," the authors write. "Prolonged use of loop diuretics was associated with higher fracture risk in postmenopausal women."

Carbone reported grant support and honorarium from Procter & Gamble and honorariums from Merck, Novartis and Aventis.

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Low Testosterone Linked to Fracture Risk in Older Men

by Zalman S. Agus, MD
SYDNEY, Australia, Jan. 15 -- Men older than 60 with low blood testosterone levels may have a higher risk for hip and non-vertebral fractures, researchers here reported.
The fracture rate was 30% higher for non-vertebral fractures for such men and almost 90% higher for hip fractures, Christian Meier, M.D., of the University of Sydney, and colleagues, reported in the Jan. 14 issue of the Archives of Internal Medicine.
Yet the investigators cautioned that if androgen therapy for the prevention of fragility fracture in healthy men is justified on efficacy and safety grounds, it should be so for only those with the most severe testosterone deficiency.
Androgens affect body composition, the researchers pointed out, and may result in a decrease in muscle mass, thereby impairing balance.
The investigators, noting that a third of all osteoporotic fractures occur in men, studied 609 community-dwelling men older than 60 (mean age 72.6) from January 1989 through December 2005, with a median follow-up of 5.8 years (up to 13 years).
Clinical risk factors, including bone mineral density and lifestyle factors, were assessed at baseline. Serum testosterone and estradiol levels were measured by tandem mass spectrometry.
During follow-up, 113 men had at least one low-trauma fracture, and 25 had multiple incident fractures. A total of 149 fractures were reported, including 55 vertebral, 27 hip, 28 rib, six wrist, and 16 upper- and 17 lower-extremity fractures.
A total of 79.3% of all new fractures occurred in men ages 70 or older, in whom the rate was 4.7% (95% CI: 4.6% to 4.8%), representing a 2.27-fold higher rate than among men younger than 70.
Analyzing testosterone levels, the researchers found that the risk of fracture was significantly increased in men with reduced testosterone levels (hazard ratio: 1.33, 95% CI: 1.09 to 1.62).
After adjustment for sex hormone-binding globulin, serum testosterone (HR: 1.48, 95% CI: 1.22 to 1.78) and serum estradiol levels (HR: 1.21, 95% CI: 1.00 to 1.47) were associated with overall fracture risk.
However, following further adjustment for major fracture risk factors (age, weight, bone mineral density, fracture history, smoking status, calcium intake, and sex hormone-binding globulin), only lower testosterone was still associated with increased risk of fracture, particularly with hip (HR: 1.88, 95% CI: 1.24 to 2.82) and non-vertebral fractures (HR: 1.32, 95% CI: 1.03 to 1.68).
After risk-factor adjustment, the risk of any fracture increased between 30% and 40% for each standard deviation decrease in serum testosterone levels, the researchers reported.
On the other hand, circulating testosterone was not significantly associated with the risk of vertebral fractures, the researchers said. This, they added, might reflect a limitation of the diagnostic method for identifying asymptomatic vertebral deformities.
Lower bone mineral density and accelerated bone resorption have been shown to be independent determinants of fractures risk in elderly men, the researchers wrote. However, serum testosterone levels and bone mineral density were independently associated with fracture risk in this study. So changes in bone mineral density only partly explain the fracture risk in this study.
Clearly, the researchers said, these findings cannot be interpreted as an indication of any causal relationship between circulating testosterone and fracture risk. Also, the homogeneity of ethnicity in this study suggests that its results cannot be generalized to other populations.
Furthermore, they said, as in any long-term study, serum samples were stored in the freezer for up to 13 years, although these samples are still likely to be stable, the researchers noted.
Finally, they said serum was not collected consistently in the morning, which could introduce random measurement error.
The researchers concluded that while low levels of estradiol and testosterone were associated with an increased fracture risk in these men, only testosterone was independent of other established risk fractures.
"While testosterone may affect fracture risk via skeletal and non-skeletal mechanisms, the present findings suggest that measurement of serum testosterone provides additional clinical information for the assessment of fracture risk in elderly men."
This study was supported by the National Health and Medical Research Council of Australia and the ARUP Institute for Clinical and Experimental Pathology.
Dr. Meier is the recipient of a medical research fellowship from the Swiss National Science Foundation and a research fellowship from the Margarete und Walter Lichtenstein Stiftung der Universität Basel.
No financial conflicts were reported.
Primary source: Archives of Internal MedicineSource reference:Meier C, et al "Endogenous sex hormones and incident fracture risk in older men: the Dubbo Osteoporosis Epidemiology Study" Arch Intern Med 2008; 168: 47-54.

Calcium Supplements Linked to Lower Fracture Risk in Older Adults

Calcium supplementation lowers fracture risk among older adults, according to a meta-analysis published in Lancet.
>Data were extracted from 29 placebo-controlled trials of calcium supplementation (with or without vitamin D) that enrolled people aged 50 or older.
Seventeen trials reporting fracture as an endpoint found a 12% reduction in risk with calcium or calcium plus vitamin D. The treatment effect was largest among adults older than 70, as well as for calcium doses of 1200 mg or more, or vitamin D doses of 800 IU or more. In 24 trials reporting on bone mineral density, supplementation was associated with a significant reduction in bone loss at the hip and spine.
The authors say that to prevent one fracture, 63 patients would need to receive calcium supplements for 3.5 years — making calcium "comparable to other preventive treatments such as statins." To prevent one fracture among "elderly" adults, they note, the NNT dropped to 30 or fewer.

Proximal Femur Bone Density Predicts Fractures in Women Better Than That of Lumbar Spine

August 23, 2007 — Proximal femur bone density measurements consistently outperformed lumbar spine measurements for global fracture prediction in women, according to the results of a historical cohort study reported in the August 13/27 issue of the Archives of Internal Medicine.
"Bone density measurement with dual-energy x-ray absorptiometry [DXA] is widely used for fracture risk assessment," write William D. Leslie, MD, MSc, from the University of Manitoba in Winnipeg, Canada, and colleagues from the Manitoba Bone Density Program. "Discordance between measurement sites is common, but it is unclear how this affects fracture prediction."
Using a database containing all clinical DXA test results for the province of Manitoba, Canada, the investigators identified a study cohort of 16,505 women aged 50 years or older at the time of baseline DXA of the spine and hip. The mean period of observation was 3.2 ± 1.5 years.
After bone density testing, each woman's longitudinal health service record was evaluated for the presence of fracture codes. The likelihood ratio test was used to determine the improvement in fracture prediction from Cox proportional hazards models with bone density covariates from a single site or from combined sites.
For osteoporotic fracture, age-adjusted hazard ratios (HRs) per SD ranged from 1.61 (95% confidence interval [CI], 1.39 - 1.87) for the lumbar spine to 1.85 (95% CI, 1.70 - 2.01) for the total hip. HRs were intermediate for the femoral neck (HR, 1.76; 95% CI, 1.62 - 1.92) and trochanter (HR, 1.77; 95% CI, 1.63 - 1.92).
Using the minimum bone density measurement was no better than using a hip measurement alone in predicting fractures. As long as the total hip measurement was included in a fracture prediction model for the overall population, none of the other measurements added significant predictive value. In the prediction of spinal fractures alone, the spine was the most useful site.
Limitations of the study include ascertainment of fractures from administrative health data and inclusion of few women of nonwhite race or ethnicity, limiting generalizability.
"Proximal femur bone density measurements consistently outperformed lumbar spine measurements for global fracture prediction," the study authors write. "In this cohort, the total hip was the best site for overall fracture assessment."
The CHAR/GE Healthcare Development Awards Programme funded this study in part. Dr. Leslie has disclosed various financial relationships with Merck Frosst Canada and Proctor & Gamble Pharmaceuticals.
Arch Intern Med. 2007;167:1641-1647.

Active Men Lessen Later Fracture Risk

UPPSALA, Sweden, June 19 -- Osteoporotic fracture may be less common among men than women, but a lifetime of physical activity appears to be just as important in reducing this risk, researchers found.
Fragility hip fractures were more than twice as common among men who reported little recreational exercise during 35 years of follow-up as among those who participated in sports at least three hours a week, found Karl Michaëlsson, M.D., Ph.D., of University Hospital here, and colleagues in a longitudinal study.
One-third of all hip fractures among men could be prevented by regular participation in sports, they wrote online in the journal PLoS Medicine.
This finding "is fully concordant with a similar analysis in women," noted Harri Sievänen, Ph.D., and Pekka Kannus, M.D., Ph.D., both of the UKK Institute in Tampere, Finland, in an accompanying editorial.
For postmenopausal women, moderate exercise has been shown to substantially lower hip fracture risk. For men, though, prospective observational studies have had inconsistent results.
"Given these inconsistent findings, the results … represent an important advance," Drs. Sievänen and Kannus wrote.
Dr. Michaëlsson and colleagues analyzed the physical activity component of the Uppsala Longitudinal Study of Adult Men, which surveyed 2,205 men in the city who were ages 49 to 51 when the study began in the early 1970s.
At baseline and at age 60, 70, 77, and 82 the participants completed questionnaires asking about how they spent their leisure time.
Half reported that they engaged in active sports or heavy gardening for at least three hours a week, or regularly engaged in hard physical training or competitive sports, collectively defined as high physical activity.
Another 36.4% were included in the intermediate activity category for responding that they "often" went walking or cycling for pleasure.
Only 14.7% reported spending their leisure time in mostly sedentary activities.
The men were followed for fracture using Sweden's national Hospital Discharge Register and local hospital registers and records.
During the 35-year follow-up, 482 men (22%) experienced a fracture of some type and 134 (6%) had a hip fracture.
For the three groups of men from high to low activity, the findings were:
Absolute incidence of hip fracture over the 35 years increased with less active lifestyles (20.5%, 13.3%, and 8.4%).
Hip fracture was significantly more likely among sedentary men than among those who were highly active (adjusted hazard ratio 2.56, 95% confidence interval 1.55 to 4.24) and among those with a medium activity level (HR 1.61, 95% CI 1.10 to 2.36).
Any type fracture occurred among 30.2%, 33.3%, and 43.6% of the men grouped by physical activity level, respectively, during the study.
Overall fracture risk was also significantly elevated for sedentary men compared with those with a high activity level (adjusted HR 1.57, 95% CI 1.20 to 2.07).
Men whose physical activity changed over time in the study had an intermediate risk of hip fractures.
Compared with men who maintained high physical activity, the adjusted hip fracture hazard ratio was 2.31 for those with a consistently low or medium physical activity level, 1.94 for those whose activity decreased from high to medium or from high to low, and 1.50 for those who increased from low or medium activity to high activity.
Relatively few participants reported hard physical training, but this group did not appear to gain additional protection against hip fracture compared with those who reported a high activity level (adjusted HR 0.94, 95% CI 0.34 to 2.63) or against fractures overall (adjusted HR 1.16, 95% CI 0.74 to 1.83).
Physical activity at work was not associated with fracture risk, the researchers said, although they did not present this data. Nor did it affect estimates of recreational physical activity, they said.
Based on an analysis of the population-attributable risk, the researchers estimated that about one-third of all hip fractures could have been prevented if all men maintained a high physical activity level (adjusted estimate 34%, 95% CI 14% to 50%).
"We suggest that older men should increase their leisure physical activity to reduce their risk of osteoporotic fractures," Dr. Michaëlsson and colleagues wrote, particularly because increasing activity in later life lowered risk.
The mechanisms by which activity reduces fracture risk are likely related to muscle performance and balance and bone structure and strength, the researchers noted.
Fractures caused by falls among aging people "have become a serious public health problem for our modern societies, so there is great interest in finding preventive strategies," Drs. Sievänen and Kannus wrote.
"Regular exercise is undoubtedly one of the most promising preventive options," the editorialists wrote.
However, further study is needed to define the best type, intensity, frequency, and duration of activity for different target populations, they added.
The study was supported by the Swedish Research Council. The researchers reported no competing interests. The editorialists reported no conflicts of interest. Additional source: Public Library of Science MedicineSource reference: Sievänen H, Kannus P "Physical activity reduces the risk of fragility fracture" PLoS Med 2007;4:e222. Additional source: Public Library of Science MedicineSource reference: Michaelsson K, et al "Leisure physical activity and the risk of fracture in men" PLoS Med 2007;4:e199.