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Management of osteoporosis of the oldest old

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An Erratum to this article was published on 01 August 2014

Abstract

Summary

This consensus article reviews the diagnosis and treatment of osteoporosis in geriatric populations. Specifically, it reviews the risk assessment and intervention thresholds, the impact of nutritional deficiencies, fall prevention strategies, pharmacological treatments and their safety considerations, the risks of sub-optimal treatment adherence and strategies for its improvement.

Introduction

This consensus article reviews the therapeutic strategies and management options for the treatment of osteoporosis of the oldest old. This vulnerable segment (persons over 80 years of age) stands to gain substantially from effective anti-osteoporosis treatment, but the under-prescription of these treatments is frequent.

Methods

This report is the result of an ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis) expert working group, which explores some of the reasons for this and presents the arguments to counter these beliefs. The risk assessment of older individuals is briefly reviewed along with the differences between some intervention guidelines. The current evidence on the impact of nutritional deficiencies (i.e. calcium, protein and vitamin D) is presented, as are strategies to prevent falls. One possible reason for the under-prescription of pharmacological treatments for osteoporosis in the oldest old is the perception that anti-fracture efficacy requires long-term treatment. However, a review of the data shows convincing anti-fracture efficacy already by 12 months.

Results

The safety profiles of these pharmacological agents are generally satisfactory in this patient segment provided a few precautions are followed.

Conclusion

These patients should be considered for particular consultation/follow-up procedures in the effort to convince on the benefits of treatment and to allay fears of adverse drug reactions, since poor adherence is a major problem for the success of a strategy for osteoporosis and limits cost-effectiveness.

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Acknowledgments

The authors would like to thank Jeremy Grierson PhD, for his assistance in preparing the draft of the manuscript from the presentations and discussions of the working group participants.

Funding was provided by the Medical Research Council of UK (C. Cooper), by Instituto Carlos III, Spanish Ministry of Science and Innovation and EU FEDER (A. Diez-Perez), by the US Department of Agriculture under agreement No. 58-1950-0-014 (R.A. Fielding) (The U.S. Department of Agriculture wishes to note that the opinions, findings, conclusion, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the Department).

Conflicts of interest

RR: has received consulting and lecture fees from Merck Sharp and Dohme, Eli Lilly, Amgen, Servier, and Danone. SB: had received grants for research support from Amgen, Merck, Sanofi, Procter & Gamble Pharmaceuticals, and Servier, and consulting fees from Warner Chilcott and Sanofi. He died unexpectedly before the finalisation of this manuscript. MLB: has received consulting and/or grant recipient from Amgen, Eli Lilly, MSD, Novartis, NPS, Roche, and Servier. OB: has received grant support from IBSA, Merck Sharp and Dohme, Nutraveris, Novartis, Pfizer, Rottapharm, Servier, and Theramex; lecture fees from IBSA, Rottapharm, Servier, and SMB. PC: has received consulting and lecture fees from Bristol-Myers Squibb, Glaxo SmithKline, Gilead, Janssen, Pfizer, Roche, Sanofi-Aventis, Schering-Plough, Servier and Vifor. CC: has received honoraria and consulting fees from Amgen, Glaxo SmithKline, ABBH, Merck Sharpe and Dohme, Eli Lilly, Pfizer, Novartis, Servier, Medtronic and Roche. ADP: has served as advisor or speaker for Amgen, GSK, MSD, Novartis, Eli Lilly and ViiV. Got research grants from Amgen. Owns stocks of Active Life Scientific. JD: is an employee of Atlantis Healthcare. RAF: has had remuneration, has played a consultant/advisory role, and has stock ownership of or funding from Eli Lilly, Dairy Management, Abbott, Pronutria, Segterra, Ammonett, Bristol Myers Squibb, Cytokinetics, Regeneron, Pfizer, Astellas, and Nestec. NCH: has received consultancy, lecture fees and honoraria from Alliance for Better Bone Health, AMGEN, MSD, Eli Lilly, Servier, Shire, Consilient Healthcare and Internis Pharma. MH: has received research grant, lecture fees, and/or consulting fees from Amgen, Pfizer, Novartis, Servier, and SMB. JAK: has worked with and received funding from many companies and non-governmental organizations dealing with skeletal metabolism including research funding from the Health Technology Assessment NHS R&D HTA Programme of the UK. JP: nothing to disclose. JR: has received consulting fees or paid advisory boards from Amgen, Merck, Servier; Lecture fees for Amgen, Lilly, Madaus, Novartis, Servier, Teva. JW: has given talks, conducted research and overseen the development of patient support programmes for Abbot, Abbvie, AstraZeneca, Genzyme, Leo, Novartis, Roche, Servier and Sobi. JYR: has received consulting fees or paid advisory boards for Servier, Novartis, Negma, Lilly, Wyeth, Amgen, Glaxo SmithKline, Roche, Merckle, Nycomed-Takeda, NPS, Theramex, and UCB; lecture fees from Merck Sharp and Dohme, Lilly, Rottapharm, IBSA, Genevrier, Novartis, Servier, Roche, Glaxo SmithKline, Teijin, Teva, Ebewee Pharma, Zodiac, Analis, Theramex, Nycomed, Novo-Nordisk, and Nolver; Grant support from Bristol Myers Squibb, Merck Sharp and Dohme, Rottapharm, Teva, Lilly, Novartis, Roche, Glaxo SmithKline, Amgen, and Servier. YT: is vice president of the International Research Institute Servier.

The golden rules of osteoporosis treatment

• Correct or prevent vitamin D insufficiency (≥800 IU/day)

• Ensure dietary calcium intake ~1000 mg/day

• Ensure adequate dietary protein intake ≥ 1 g/kg body wt/day

• Promote weight-bearing physical exercise

• Treat any disease that might be causing bone loss

• Reduce the risk of falls

• Reduce consequences of fall (hip protectors)

• Prescribe pharmaceutical treatment when indicated by risk assessment

• Provide adequate counselling and treatment explanation

• Follow-up patients with enquiries of persistence

• Re-evaluate therapeutic options after 3 years

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Correspondence to R. Rizzoli.

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S. Boonen passed away unexpectedly before the finalisation of the manuscript.

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Rizzoli, R., Branco, J., Brandi, ML. et al. Management of osteoporosis of the oldest old. Osteoporos Int 25, 2507–2529 (2014). https://doi.org/10.1007/s00198-014-2755-9

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