Updated recommendations for the diagnosis and management of osteoporosis: a local perspective

Postmenopausal osteoporosis and osteoporosis in elderly men are major health problems, with a significant medical and economic burden. Although osteopenia and osteoporosis are more common locally than in the West, fracture rates are generally less than in Western countries. Vitamin D deficiency is common in the region and contributes adversely to bone health. Vitamin D deficiency should be suspected and treated in all subjects with ostopenia or osteoporosis. The use of risk factors to determine fracture risk has been adopted by the World Health Organization and many international societies. Absolute fracture risk methodology improves the use of resources by targeting subjects at higher risk of fractures for screening and management. The King Faisal Specialist Hospital Osteoporosis Working Group recommends screening for women 65 years and older and for men 70 years and older. Younger subjects with clinical risk factors and persons with clinical evidence of osteoporosis or diseases leading to osteoporosis should also be screened. These guidelines provide recommendations for treatment for postmenopausal women and men older than 50 years presenting with osteoporotic fractures for persons having osteoporosis-after excluding secondary causes-or for persons having low bone mass and a high risk for fracture. The Working Group has suggested an algorithm to use at King Faisal Specialist Hospital that is based on the availability, cost, and level of evidence of various therapeutic modalities. Adequate calcium and vitamin D supplement are recommended for all. Weekly alendronate [in the absence of contraindications] is recommended as first-line therapy. Alternatives to alendronate are raloxifene or strontium ranelate. Second-line therapies are zoledronic acid intravenously once yearly, when oral therapy is not feasible or complicated by side effects, or teriparatide in established osteoporosis with fractures

Adding rosiglitazone to metformin in patients with type 2 diabetes: effect on diabetes control and metabolic parameters

To evaluate the efficacy and tolerability, any changes in lipid parameters including free fatty acids and effect on weight and blood pressure, of adding Rosiglitazone to patients with type 2 DM who are not adequately controlled on maintenance dose of Metformin. Prospective study of 14 patients with type 2 DM who were maintained on Metformin alofte [1.5-2.5 g/day]. Twelve patients met the inclusion criteria, and received 4 mg of Rosiglitazone daily in addition to Metformin. Patients were followed for 24 weeks and seen for 6-7 visits. The dose of Rosiglitazone was increased after 8 weeks if FBG was still >/= 160 mg/dl. Full biochemical evaluation was done and safety parameters were observed at base line, at intervals during the study and at the end of the study. All patients completed the study. T test was used for comparison. Eight males and four females were studied. They had the following characteristics: Mean age was [52 +/- 6.9] years, weight was [78.2 +/- 10.1] kg BMI was [28 +/- 4] kg/m[2], waist circumference was [97.5 +/- 6.5] cm, and duration of DM was [7.3 +/- 6] years. Four patients required an increase of Rosiglitazone dose to 8 mg after 8 weeks. All patients showed improvement of HbAlc levels by the end of the study. When mean base line parameters were compared to those at the end of study: HbAlc level dropped from [8.9% +/- 1.5] to [7.1% +/- 1.1] [P: 0.00003] and FBG from [205 + 50.6] to [150 +/- 28] mg/dl [P: 0.002]. Free Fatty Acids [FFA] dropped from [703 +/- 213] to [510 +/- 303.6] by 8 weeks and to [574 +/- 184.6] microeq/L by the end of the study, [P: 0.01 and 0.06, respectively]. Improvement in HbAlc did not however correlate with the level of FFA drop. There was also significant increase in HDL level [1.15 +/- 0.14]-[1.27 +/- 0.2] mmol/L, [P: 0.02], and weight [78.2 +/- 10.1]-[80.1 +/- 10.9] kg [P: 0.01]. The changes in LDL [3.02 +/- 0.57] - [3.23 +/- 0.5] mmol/L, TG [2.16 +/- l.l]-[2.2 +/- 1.33] mmol/L, waist circumference [97.5 +/- 6.5]-[99 +/- 8.1] cm, and BP [132.5 +/- 17]-[130.2 +/- 18.8] mm Hg [systolic], were not significant. When [Good Responders], [HbAlc drop of >1.5%], [nine subjects] were compared to those with less than 1.5% drop [three subjects], there were no specific characteristics to define responders. Rosiglitazone, added to Metformin in type 2 DM patients, was effective and well tolerated. There was a significant decrease in FFA levels with treatment. The response to treatment, however could not be predicted from biochemical or clinical parameters. A larger study may be needed to define respon-der characteristics

case of vitamin D deficiency masquerading as occult malignancy

At present, the diagnosis of a [brown tumor] is a clinical curiosity. It is considered to be a complication of severe and rapidly progressive hyperparathyroidism [HPT]. Indeed, such a presentation is typical of a patient harboring a parathyroid carcinoma. The incidence of brown tumors is 3% in the benign form of primary hyperparathyroidism [1]. In secondary HPT, the incidence of brown tumors is under 2% and is caused by chronic renal failure.[1] Brown tumors are locally destructive lesions consisting of fluid-filled cysts that are rich in highly vascularized fibrous tissue containing hemorrhagic spots. Blood pigment [hemosiderin] will accumulate, which imparts a reddish-brown hue and hence the name [brown tumor].[1] Brown tumors are demonstrated radiologically as lesions of osteitis fibrosa cystica [1]. We describe a young lady who was erroneously diagnosed elsewhere as a case of metastatic bone disease. Our evaluation documented this as a case of vitamin D deficiency [VDD] causing secondary hyperparathyroidism [SHPT] with diffuse distribution of brown tumors in her skeleton. Following vitamin D and calcium treatment, the patient improved

hook effect in prolactin immunoassays

We describe a young female patient with giant invasive sellar and suprasellar tumor and modest elevation of prolactin to 165 ng/ml normal range 3-29. A diagnosis was made of non functional pituitary adenoma with stalk effect, causing moderate prolactin elevation. A surgery for the removal of the tumor was advised but the patient declined. Treatment with a dopamine agonist was not offered. The patient presented 2 years later with deterioration of her vision and serum prolactin of >16000 ng/ml. Debulking transsphenoidal surgery was performed. The staining of tissue confirmed prolactinoma. Medical treatment with bromocriptine was initiated. We believe that the discrepancy between the 2 values of serum prolactin, is most probably caused by a hook effect in the initial prolactin assay. The mechanism of the hook effect and its occurrence with prolactin immunoassays and methods to eliminate this effect is discussed. Hook effect needs to be suspected in every patient with a giant pituitary or parasellar mass and serum prolactin <200 ng/ml. Assaying a diluted serum will usually unmask this phenomenon and allow accurate diagnosis and management