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Archives of Osteoporosis

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01-12-2012 | Original Article

The prevalence of recognized contributors to secondary osteoporosis in South East Asian men and post-menopausal women. Are Z score diagnostic thresholds useful predictors of their presence?

Authors: Chee Kwang Yung, Stephanie Fook-Chong, Manju Chandran

Published in: Archives of Osteoporosis | Issue 1-2/2012

Abstract

Summary

The prevalence of secondary contributors to osteoporosis in our population of SE Asian patients is high. Though various low thresholds Z score values have been proposed as suggestive of a high likelihood of secondary osteoporosis, they appear to have only limited discriminatory value in identifying a secondary cause.

Introduction

Many patients with osteoporosis have significant secondary contributors towards their bone loss. The sensitivity and diagnostic utility of using Z score thresholds to screen for secondary osteoporosis have not yet been convincingly demonstrated nor has there been any previous attempt to estimate the prevalence of secondary osteoporosis in South East Asia. We aimed to study the prevalence of commonly recognized contributors and to determine the discriminatory ability of Z score thresholds in screening for them in Singaporean men and post-menopausal women with osteoporosis.

Method

Three hundred thirty-two consecutive patients seen at the osteoporosis clinic of the largest hospital in Singapore were evaluated. The frequencies of the different contributors were determined and sensitivities, specificities, and positive and negative predictive values (PPV and NPV) of pre-specified Z score cut-off values calculated.

Results

Vitamin D deficiency was present in 18.5% of the patients, hyperthyroidism in 10.11%, primary hyperparathyroidism in 1%, secondary hyperparathyroidism in 6%, hypercalciuria in 21.63%, glucocorticoid use in 8.43%, and hypogonadism in 9.4% of males. A Z score value of <−1 had a sensitivity of 71.7 % and NPV of 66.2 % in identifying the presence of a secondary contributor in post-menopausal women. The sensitivity and NPV of a similar threshold in men was 59.1 and 40 %, respectively. ROC curves used to investigate various Z score diagnostic thresholds for sensitivity and specificity showed that they provided poor predictive value for the presence of secondary osteoporosis.

Conclusion

Secondary contributors are common in our patients with osteoporosis. Z score diagnostic thresholds have only limited value in discriminating between primary and secondary osteoporosis.

Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR (2009) Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 301(5):513–521, Feb 4PubMedCrossRef

Lau EM, Lee JK, Suriwongpaisal P, Saw SM, De Das S, Khir A et al (2001) The incidence of hip fracture in four Asian countries: the Asian Osteoporosis Study (AOS). Osteoporos Int 12(3):239–243PubMedCrossRef

Painter SE, Kleerekoper M, Camacho PM (2006) Secondary osteoporosis: a review of the recent evidence. Endocrine Practice July-Aug 12(4):436–445

Tannenbaum C, Clark J, Schwartzman K, Wallenstein S, Lapinski R, Meier D (2002) Yield of laboratory testing to identify secondary contributors to osteoporosis in otherwise healthy women. J Clin Endocrinol Metab 87(10):4431–4437PubMedCrossRef

Moreira Kulak CA, Schussheim DH, McMahon DJ, Kurland E, Silverberg SJ, Siris ES et al (2000) Osteoporosis and low bone mass in premenopausal and perimenopausal women. Endocr Pract Aug 6(4):296–304

Sikon AL, Thacker HL, Carey J, Deal C, Licata AA (2006) Secondary osteoporosis: are we recognizing it? J Womens Health (Larchmt) 15(10):1174–1183CrossRef

Swaminathan K, Flynn R, Garton M, Paterson C, Leese G (2009) Search for secondary osteoporosis: are Z scores useful predictors? Postgrad Med JJan 85(999):38–39CrossRef

Stein E, Shane E (2003) Secondary osteoporosis. Endocrinol Metab Clin North Am 32(1):115–134PubMedCrossRef

McKiernan FE, Berg RL, Linneman JG (2011) The utility of BMD Z-score diagnostic thresholds for secondary causes of osteoporosis. Osteoporos Int Apr 22(4):1069–1077CrossRef

10.

Academy of Medicine of Malaysia and Malaysian Osteoporosis Society (2001) Clinical Practice Guidelines on Management of Osteoporosis

11.

The working group for formulating clinical management guidelines for osteoporosis in Hong Kong (1998) Clinical management guidelines for osteoporosis in Hong Kong. Hong Kong Med J 4(4):423–431

12.

Ministry of Health, Singapore (2009) Clinical guidelines on osteoporosis

13.

Koh LK, Sedrine WB, Torralba TP, Kung A, Fujiwara S, Chan SP et al (2001) A simple tool to identify Asian women at increased risk of osteoporosis. Osteoporos Int 12(8):699–705PubMedCrossRef

14.

Mauck KF, Clarke BL (2006) Diagnosis, screening, prevention and treatment of osteoporosis. Mayo Clin Proc May 81(5):662–672CrossRef

15.

Thoo FL, Chng SM, Lam KS et al (2002) To establish the normal bone mineral density reference database for the Singaporean male. Ann Acad Med Singapore 31:21–25PubMed

16.

Leong KH, Feng PH (1997) Bone mineral density measurements using the Hologic QD 2000 in 175 Singaporean women aged 20–80. Singapore Med J 38(1):25–26PubMed

17.

Levey AS, Coresh J, Balk E et al (2003) National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification and stratification. Ann Int Med 134:161–170

18.

Heaney RP, Recker R, Ryan RA (1999) Urinary calcium in perimenopausal women: normative values. Osteoporos Int 9(1):13–18PubMedCrossRef

19.

Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Vieth R (2005) Estimates of optimal vitamin D status. Osteoporos Int Jul 16(7):713–716CrossRef

20.

Chandran M, Hoeck HC, Wong HC, Zhang RF, Dimai HP (2010) Vitamin D status and its relationship with bone mineral density and parathyroid hormone in South-East Asian adults with low bone density. Endocr Pract Nov 1:1–24CrossRef

21.

Lips P (2001) Vitamin D deficiency and secondary hyperparathyroidism in the elderly: consequences for bone loss and fractures and therapeutic implications. Endocr Rev 22(4):477–501PubMedCrossRef

22.

Sahota O, Gaynor K, Harwood RH, Hosking DJ (2001) Hypovitaminosis D and “functional hypoparathyroidism”: the NoNOF (Nottingham Neck of Femur) study. Age Ageing 30:467–472PubMedCrossRef

23.

Melton LJ, Crowson CS, Khosla S, Wilson DM, O’Fallon WM (1998) Fracture risk among patients with urolithiasis: a population-based cohort study. Kidney Int Feb 53(2):459–464CrossRef

24.

Giannini S, Nobile M, Dalle Carbonare L, Lodetti MG, Sella S, Vittadello G (2003) Hypercalciuria is a common and important finding in postmenopausal women with osteoporosis. Eur J Endocrinol 149(3):209–213PubMedCrossRef

25.

Teucher B, Dainty JR, Spinks CA, Majsak-Newman G, Berry DJ, Hoogewerff JA (2008) Sodium and bone health: impact of moderately high and low salt intakes on calcium metabolism in postmenopausal women. J Bone Miner Res 23(9):1477–1485PubMedCrossRef

26.

Department of Nutrition, Ministry of Health (1998) National nutrition survey of Singapore, 1998

27.

Saggar-Malik AK, Markandu ND, MacGregor GA, Cappuccio FP (1996) Case report: moderate salt restriction for the management of hypertension and hypercalciuria. J Hum HypertensDec 10(12):811–813

28.

Jódar E, Muñoz-Torres M, Escobar-Jiménez F, Quesada-Charneco M, del Castillo JD Lund (1997) Bone loss in hyperthyroid patients and in former hyperthyroid patients controlled on medical therapy: influence of aetiology and menopause. Clin Endocrinol (Oxf) 47(3):279–285CrossRef

29.

Bours SP, van Geel TA, Geussens P, Janssen MJ, Janzing HM, Hoffland GA, Willems PC, van den Bergh JP (2011) Contributors to secondary osteoporosis and metabolic bone diseases in patients presenting with a clinical fracture. J Clin Endocrinol Metab 96(5):1360–1367, Epub 2011 Mar 16PubMedCrossRef

30.

van de Ven AC, Erdtsieck RJ (2008) Changes of bone mineral density, quantitative ultrasound parameters and markers of bone turnover during treatment of hyperthyroidism. Neth J MedNov 66(10):428–432

31.

Bilezikian JP, Khan AA, Potts JT, on behalf of the Third International Workshop on the Management of Asymptomatic Primary Hyperthyroidism (2009) Guidelines for the Management of Asymptomatic Primary Hyperparathyroidism: Summary Statement from the Third International Workshop. J Clin Endocrinol Metab 94(2):335–339, 2PubMedCrossRef

32.

Di Monaco M, Vallero F, Di Monaco R, Mautino F, Cavanna A (2004) Primary hyperparathyroidism in elderly patients with hip fracture. J Bone Miner Metab 22(5):491–495PubMedCrossRef

33.

Edwards BJ, Langman CB, Bunta AD, Vicuna M, Favus M (2008) Secondary contributors to bone loss in osteoporosis related hip fractures. Osteoporos Int 19:991–999PubMedCrossRef

34.

Danese MD, Kim J, Doan QV, Dylan M, Griffiths R, Chertow GM (2006) PTH and the risks for hip, vertebral, and pelvic fractures among patients on dialysis. Am J Kidney Dis 47(1):149–156PubMedCrossRef

35.

Rudser KD, de Boer IH, Dooley A, Young B, Kestenbaum B (2007) Fracture risk after parathyroidectomy among chronic hemodialysis patients. J Am Soc Nephrol 18(8):2401–2407PubMedCrossRef

36.

Tracz MJ, Sideras K, Boloña ER, Haddad RM, Kennedy CC, Uraga MV (2006) Testosterone use in men and its effects on bone health. A systematic review and meta-analysis of randomized placebo-controlled trials. J Clin Endocrinol Metab 91(6):2011–2016PubMedCrossRef

37.

Leib ES, Saag KG, Adachi JD et al (2011) Official positions for FRAX(®) clinical regarding glucocorticoids: Official Positions for FRAX® Clinical Regarding Glucocorticoids: The impact of the use of glucocorticoids on the estimate by FRAX(®) of the 10 year risk of fracture. From Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX(®). J Clin Densitom 14:212–219PubMedCrossRef

38.

Watts NB, Lewiecki EM, Miller PD, Baim S (2008) National Osteoporosis Foundation 2008 Clinician’s Guide to Prevention and Treatment of Osteoporosis and the World Health Organization Fracture Risk Assessment Tool (FRAX): what they mean to the bone densitometrist and bone technologist. J Clin Densitom Dec 11(4):473–477CrossRef

39.

Grossman JM, Gordon R, Ranganath VK (2010) American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthr Care Res 62:1515–1526CrossRef

40.

Kanis JA, Burlet N, Cooper C, Delmas PD, Reginster J, Borgstrom F et al (2008) European guidelines for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int Apr 19(4):399–428CrossRef

41.

Jamal SA, Leiter RE, Bayoumi AM, Bauer DC, Cummings SR (2005) Clinical utility of laboratory testing in women with osteoporosis. Osteoporos Int May 16(5):534–540CrossRef

42.

Stenson WF, Newberry R, Lorenz R, Baldus C, Civitelli R (2005) Increased prevalence of celiac disease and need for routine screening among patients with osteoporosis. Arch Intern Med 165:393–399PubMedCrossRef

43.

Abrahamsen B, Andersen I, Christensen SS, Skov Madsen J, Brixen K (2005) Utility of testing for monoclonal bands in serum of patients with suspected osteoporosis: retrospective, cross sectional study. BMJ 330:818PubMedCrossRef

44.

Landgren O, Weiss BM (2009) Patterns of monoclonal gammopathy of undetermined significance and multiple myeloma in various ethnic/racial groups: support for genetic factors in pathogenesis. Leukemia Oct 23(10):1691–1697CrossRef

45.

Fasano A, Berti I, Gerarduzzi T, Not T, Colletti RB, Drago S, Elitsur Y, Green PH, Guandalini S, Hill ID, Pietzak M, Ventura A, Torpe M, Kryszak D, Fornaroli F, Wasserman SS, Murray JA, Horvath K (2003) Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med 163(3):286–292PubMedCrossRef

Title: The prevalence of recognized contributors to secondary osteoporosis in South East Asian men and post-menopausal women. Are Z score diagnostic thresholds useful predictors of their presence?
Authors: Chee Kwang Yung
Stephanie Fook-Chong
Manju Chandran
Publication date: 01-12-2012
Publisher: Springer-Verlag
Published in: Archives of Osteoporosis / Issue 1-2/2012
Print ISSN: 1862-3522
Electronic ISSN: 1862-3514
DOI: https://doi.org/10.1007/s11657-012-0078-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

The prevalence of recognized contributors to secondary osteoporosis in South East Asian men and post-menopausal women. Are Z score diagnostic thresholds useful predictors of their presence?

Abstract

Summary

Introduction

Method

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Summary

Introduction

Method

Results

Conclusion

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