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Fractures, Osteoporosis, and the Endocrinologist

Fractures, Osteoporosis, and the Endocrinologist Kiebzak et al1 in their article titled "Undertreatment of Osteoporosis in Men With Hip Fracture" have identified a real problem in the treatment of patients with fractures. The responses by Abraham2 and Mikhail3 and the replies by Kiebzak et al4,5 further identify the issues that need to be addressed before patients with fracture can obtain optimum care. Just as it would not be in the patient's best interest for an endocrinologist to attempt to treat a fracture, neither is treatment of osteoporosis of this magnitude without referral to an endocrinologist with expertise in treating bone disease in the patient's best interest. The article1 and ensuing letters2-5 allude to the issues, but the endocrinologist's approach has not been considered in the treatment plan. Treatment of osteoporosis that has advanced to the fracture stage is not a quick-fix situation; rather, it is a long-term problem that needs as much expertise as that required to do hip replacement. Many men with fractures have low bone mass, and a high percentage of them have hypogonadism (bioavailable testosterone level <400 ng/dL [<14 nmol/L]); vitamin D deficiency (25-hydroxyvitamin D level <25 ng/mL [<62 nmol/L]; free calcium level <72 mg/dL [<18 mmol/L]); and/or secondary hyperparathyroidism with a parathyroid hormone level above 50 pg/mL. Each of these conditions can be safely treated, but treatment needs to be part of an ongoing program developed and monitored by an endocrinologist. The fears concerning the effect of the addition of testosterone on the prostate in these patients have been laid to rest.6-8 Uncovering a latent prostate cancer by obtaining a prostate-specific antigen level at the onset of treatment and again after 4 weekly intramuscular injections of 200 mg of testosterone enanthate to detect a 25% or greater rise in the prostate-specific antigen (the prostate stress test)9 can only be beneficial to the patient. Restoring and maintaining the vitamin D and free calcium levels is an ongoing process best handled by a knowledgeable endocrinologist. While the endocrinologist is best able to determine whether a bisphosphonate, teriparatide, or both are indicated and when they should be introduced into the patient's program, physicians other than endocrinologists can monitor this treatment, but they must have the time, resources, and expertise to provide optimum care. References 1. Kiebzak GMBeinart GAPerser KAmbrose CGSift SJHeggeness MH Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med. 2002;1622217- 2222PubMedGoogle ScholarCrossref 2. Abraham A Undertreatment of osteoporosis in men who have had a hip fracture [letter]. Arch Intern Med. 2003;1631236PubMedGoogle ScholarCrossref 3. Mikhail N Hypogonadism and osteoporosis in men [letter]. Arch Intern Med. 2003;1631237PubMedGoogle ScholarCrossref 4. Keibzak GMBeinart GAPerser KAmbrose CGSiff SJHeggeness MH In reply [letter]. Arch Intern Med. 2003;1631236- 1237Google ScholarCrossref 5. Keibzak GMBeinart GAPerser KAmbrose CGSiff SJHeggeness MH In reply [letter]. Arch Intern Med. 2003;1631237- 1238Google ScholarCrossref 6. Thorpe ANeal D Benign prostatic hyperplasia. Lancet. 2003;3611359- 1367PubMedGoogle ScholarCrossref 7. Zitzmann MDepenbusch MGromoll JNieschlag E Prostate volume and growth in testosterone-substituted hypogonadal men are dependent on the CAG repeat polymorphism of the androgen receptor gene: a longitudinal pharmacogenetic study. J Clin Endocrinol Metab. 2003;882049- 2054PubMedGoogle ScholarCrossref 8. Sirovich BSchwartz LWoloshin S Screening men for prostate and colorectal cancer in the United States: does practice reflect the evidence? JAMA. 2003;2891414- 1420PubMedGoogle ScholarCrossref 9. Behre HMBohmeter JNieschlag E Prostate volume in testosterone-treated and untreated hypogonadal men in comparison to age-matched normal controls. Clin Endocrinol (Oxf). 1994;40341- 349PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Fractures, Osteoporosis, and the Endocrinologist

Field, Morton H.
Archives of Internal Medicine , Volume 163 (22) – Dec 8, 2003
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Fractures, Osteoporosis, and the Endocrinologist

Abstract

Kiebzak et al1 in their article titled "Undertreatment of Osteoporosis in Men With Hip Fracture" have identified a real problem in the treatment of patients with fractures. The responses by Abraham2 and Mikhail3 and the replies by Kiebzak et al4,5 further identify the issues that need to be addressed before patients with fracture can obtain optimum care. Just as it would not be in the patient's best interest for an endocrinologist to attempt to treat a fracture, neither is...
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References (9)

Publisher
American Medical Association
Copyright
Copyright © 2003 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.163.22.2796-a
Publisher site
See Article on Publisher Site

Abstract

Kiebzak et al1 in their article titled "Undertreatment of Osteoporosis in Men With Hip Fracture" have identified a real problem in the treatment of patients with fractures. The responses by Abraham2 and Mikhail3 and the replies by Kiebzak et al4,5 further identify the issues that need to be addressed before patients with fracture can obtain optimum care. Just as it would not be in the patient's best interest for an endocrinologist to attempt to treat a fracture, neither is treatment of osteoporosis of this magnitude without referral to an endocrinologist with expertise in treating bone disease in the patient's best interest. The article1 and ensuing letters2-5 allude to the issues, but the endocrinologist's approach has not been considered in the treatment plan. Treatment of osteoporosis that has advanced to the fracture stage is not a quick-fix situation; rather, it is a long-term problem that needs as much expertise as that required to do hip replacement. Many men with fractures have low bone mass, and a high percentage of them have hypogonadism (bioavailable testosterone level <400 ng/dL [<14 nmol/L]); vitamin D deficiency (25-hydroxyvitamin D level <25 ng/mL [<62 nmol/L]; free calcium level <72 mg/dL [<18 mmol/L]); and/or secondary hyperparathyroidism with a parathyroid hormone level above 50 pg/mL. Each of these conditions can be safely treated, but treatment needs to be part of an ongoing program developed and monitored by an endocrinologist. The fears concerning the effect of the addition of testosterone on the prostate in these patients have been laid to rest.6-8 Uncovering a latent prostate cancer by obtaining a prostate-specific antigen level at the onset of treatment and again after 4 weekly intramuscular injections of 200 mg of testosterone enanthate to detect a 25% or greater rise in the prostate-specific antigen (the prostate stress test)9 can only be beneficial to the patient. Restoring and maintaining the vitamin D and free calcium levels is an ongoing process best handled by a knowledgeable endocrinologist. While the endocrinologist is best able to determine whether a bisphosphonate, teriparatide, or both are indicated and when they should be introduced into the patient's program, physicians other than endocrinologists can monitor this treatment, but they must have the time, resources, and expertise to provide optimum care. References 1. Kiebzak GMBeinart GAPerser KAmbrose CGSift SJHeggeness MH Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med. 2002;1622217- 2222PubMedGoogle ScholarCrossref 2. Abraham A Undertreatment of osteoporosis in men who have had a hip fracture [letter]. Arch Intern Med. 2003;1631236PubMedGoogle ScholarCrossref 3. Mikhail N Hypogonadism and osteoporosis in men [letter]. Arch Intern Med. 2003;1631237PubMedGoogle ScholarCrossref 4. Keibzak GMBeinart GAPerser KAmbrose CGSiff SJHeggeness MH In reply [letter]. Arch Intern Med. 2003;1631236- 1237Google ScholarCrossref 5. Keibzak GMBeinart GAPerser KAmbrose CGSiff SJHeggeness MH In reply [letter]. Arch Intern Med. 2003;1631237- 1238Google ScholarCrossref 6. Thorpe ANeal D Benign prostatic hyperplasia. Lancet. 2003;3611359- 1367PubMedGoogle ScholarCrossref 7. Zitzmann MDepenbusch MGromoll JNieschlag E Prostate volume and growth in testosterone-substituted hypogonadal men are dependent on the CAG repeat polymorphism of the androgen receptor gene: a longitudinal pharmacogenetic study. J Clin Endocrinol Metab. 2003;882049- 2054PubMedGoogle ScholarCrossref 8. Sirovich BSchwartz LWoloshin S Screening men for prostate and colorectal cancer in the United States: does practice reflect the evidence? JAMA. 2003;2891414- 1420PubMedGoogle ScholarCrossref 9. Behre HMBohmeter JNieschlag E Prostate volume in testosterone-treated and untreated hypogonadal men in comparison to age-matched normal controls. Clin Endocrinol (Oxf). 1994;40341- 349PubMedGoogle ScholarCrossref

Journal

Archives of Internal Medicine – American Medical Association

Published: Dec 8, 2003

Keywords: osteoporosis,fractures

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