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To determine the effect of alendronate (ALN) and teriparatide on trabecular bone score (TBS) in patients with glucocorticoid-induced osteoporosis.Patients with chronic glucocorticoid therapy-induced osteoporosis (median 7.5 mg/day prednisone equivalent for ≥90 days) were randomized to receive oral ALN 10 mg/day (n = 214) or subcutaneous teriparatide 20 μg/day (n = 214) for 36 months; 118 patients in the ALN group and 123 patients in the teriparatide group completed treatment. Dual x-ray absorptiometry (DXA) results for 53 patients receiving ALN and 56 patients receiving teriparatide who had DXA scans with adequate resolution to perform TBS analysis and completed 36 months of therapy were blindly analyzed for TBS at baseline and 3, 6, 12, 18, 24, and 36 months.In teriparatide-treated patients, TBS was significantly increased at 18 months compared to baseline, and by 36 months had increased 3.7% (P 0.05). In ALN-treated patients, there was not a significant change in TBS compared to baseline at any time point. Changes in lumbar spine bone mineral density (BMD) measured by DXA in the subgroup with TBS data were similar to BMD results in the overall study population. At 36 months, increases in lumbar spine BMD were 5.5% and 10.3% in patients treated with ALN and teriparatide, respectively.In patients with glucocorticoid-induced osteoporosis, both ALN and teriparatide increased lumbar spine BMD. However, trabecular bone score significantly increased with teriparatide but did not significantly change with ALN. The pathogenesis of glucocorticoid-induced osteoporosis is predominantly reduced bone formation. TBS may represent a sensitive measure to discriminate treatment effects of an anabolic versus an antiresorptive drug in glucocorticoid-induced osteoporosis.

Drug-induced autoimmune disorders have been recognized for over 50 years. In 1945, Hoffman 60 reported drug-induced lupus (DIL) in a 19-year-old man receiving sulfadiazine who developed fever, skin rash, myalgia, nephritis, and an elevated sedimentation rate. Since then, over 70 drugs have been reported to cause a lupus-like illness. Recognition of the development of drug-induced autoimmune disorders and the development of alternative drugs to replace common offenders, such as procainamide and hydralazine, have resulted in a reduction of the incidence of DIL. With increasing use of agents that target cytokine and other immunologic pathways, however, it is possible that we may see more drug-induced autoimmune disorders in the future. This article discusses the common nonhematologic, drug-induced autoimmune disorders, including DIL, and some of the newer descriptions of autoimmune disorders believed to be related to the use of some biological agents.

Many postmenopausal women treated with teriparatide for osteoporosis have previously received antiresorptive therapy. In women treated with alendronate (ALN) or raloxifene (RLX), adding versus switching to teriparatide produced different responses in areal bone mineral density (aBMD) and biochemistry; the effects of these approaches on volumetric BMD (vBMD) and bone strength are unknown. In this study, postmenopausal women with osteoporosis receiving ALN 70 mg/week (n = 91) or RLX 60 mg/day (n = 77) for ≥18 months were randomly assigned to add or switch to teriparatide 20 µg/day. Quantitative computed tomography scans were performed at baseline, 6 months, and 18 months to assess changes in vBMD; strength was estimated by nonlinear finite element analysis. A statistical plan specifying analyses was approved before assessments were completed. At the spine, median vBMD and strength increased from baseline in all groups (13.2% to 17.5%, p 0.01); there were no significant differences between the Add and Switch groups. In the RLX stratum, hip vBMD and strength increased at 6 and 18 months in the Add group but only at 18 months in the Switch group (Strength, Month 18: 2.7% Add group, p 0.01 and 3.4% Switch group, p 0.05). In the ALN stratum, hip vBMD increased in the Add but not in the Switch group (0.9% versus -0.5% at 6 months and 2.2% versus 0.0% at 18 months, both p ≤ 0.004 group difference). At 18 months, hip strength increased in the Add group (2.7%, p 0.01) but not in the Switch group (0%); however, the difference between groups was not significant (p = 0.076). Adding or switching to teriparatide conferred similar benefits on spine strength in postmenopausal women with osteoporosis pretreated with ALN or RLX. Increases in hip strength were more variable. In RLX-treated women, strength increased more quickly in the Add group; in ALN-treated women, a significant increase in strength compared with baseline was seen only in the Add group.

To estimate the prevalence of risk factors for osteoporosis in Alaska Native (AN) women and to assess the feasibility of portable bone density measurement in rural Alaska.We conducted a cross-sectional survey of a convenience sample of 452 patients from 17 clinics in Alaska. We interviewed subjects regarding risk factors for osteoporosis and measured calcaneal bone density by ultrasound.Of the 452 women, 316 (70%) were Alaska Natives. Risk factors for osteoporosis were common among study participants. Total dietary calcium intake was low (mean = 306 mg/day). Current smokers [Odds Ratio (OR) = 3.9, 95% Confidence Interval (95% C.I.) 1.8, 8.4], former smokers (OR = 2.8, 95% C.I. 1.3, 6.2) and chronic users of oral steroids (OR = 4.7, 95% C.I. 1.8, 12.0) were at increased risk for low bone density.Reduction of cigarette smoking, increase in dietary calcium, and reduction of oral steroid use would likely decrease the prevalence of osteoporosis in AN women. A comprehensive prevention program including bone density screening is warranted in rural Alaska.

A 73 year old English woman with seropositive, nodular, severe destructive rheumatoid arthritis (RA) and secondary Sjogren’s syndrome was seen with a 10 day history of pain and five day history of swelling in the left thigh. She reported that she got out of bed 10 days ago, and felt pain in her left thigh, which she presumed to be a pulled muscle. She had difficulty in weight bearing and walking, but continued her already limited daily activities in a sheltered accommodation. Five days after this episode she noticed generalised swelling of her left thigh and developed fever (38.5°C), chills, headache, and malaise. The fever and associated symptoms resolved with high doses of acetaminophan, but the thigh pain and swelling progressively worsened to where she became bedridden. She had no history of swelling in her calves, recent surgery, prolonged immobilisation or any injury to her left thigh before the onset of pain. Her past medical history was notable for debilitating RA of 30 years duration. Over the years, she had had bilateral hip arthroplasties and hand surgeries. She had developed a severe secondary Sjogren’s syndrome (diagnosis based on clinical criteria only) with corneal ulcerations despite regular use of artificial tears and protective glasses. She had lost all of her teeth except five; she wore dentures and used artificial saliva. Over the past eight years her RA was stable with prednisone 5 mg per day, methotrexate 7.5 mg orally per week, and nabumetone 500 mg twice a day. She was a widow and lived alone in a sheltered accommodation. She did not smoke. Her son and daughter in law who lived in the same town, helped her …

Excerpt To the editor: The use of cocaine has been associated with many serious medical complications, including myocardial infarction, cardiac arrhythmias, cerebral vascular accidents, intestinal ...