Recommendations for raloxifene use in daily clinical practice in the Swiss setting.

BACKGROUND/AIM: Raloxifene is the first selective estrogen receptor modulator that has been approved for the treatment and prevention of osteoporosis in postmenopausal women in Europe and in the US. Although raloxifene reduces the risk of invasive breast cancer in postmenopausal women with osteoporosis and in postmenopausal women at high risk for invasive breast cancer, it is approved in that indication in the US but not in the EU. The aim was to characterize the clinical profiles of postmenopausal women expected to benefit most from therapy with raloxifene based on published scientific evidence to date. METHODS: Key individual patient characteristics relevant to the prescription of raloxifene in daily practice were defined by a board of Swiss experts in the fields of menopause and metabolic bone diseases and linked to published scientific evidence. Consensus was reached about translating these insights into daily practice. RESULTS: Through estrogen agonistic effects on bone, raloxifene reduces biochemical markers of bone turnover to premenopausal levels, increases bone mineral density (BMD) at the lumbar spine, proximal femur, and total body, and reduces vertebral fracture risk in women with osteopenia or osteoporosis with and without prevalent vertebral fracture. Through estrogen antagonistic effects on breast tissue, raloxifene reduces the risk of invasive estrogen-receptor positive breast cancer in postmenopausal women with osteoporosis and in postmenopausal women at high risk for invasive breast cancer. Finally, raloxifene increases the incidence of hot flushes, the risk of venous thromboembolic events, and the risk of fatal stroke in postmenopausal women at increased risk for coronary heart disease. Postmenopausal women in whom the use of raloxifene is considered can be categorized in a 2 × 2 matrix reflecting their bone status (osteopenic or osteoporotic based on their BMD T-score by dual energy X-ray absorptiometry) and their breast cancer risk (low or high based on the modified Gail model). Women at high risk of breast cancer should be considered for treatment with raloxifene. CONCLUSION: Postmenopausal women between 50 and 70 years of age without climacteric symptoms with either osteopenia or osteoporosis should be evaluated with regard to their breast cancer risk and considered for treatment with raloxifene within the framework of its contraindications and precautions.

[Can we still give a fibromyalgia diagnosis?]. / Peut-on encore poser le diagnostic de fibromyalgie?

This article is an attempt at a critical analysis of the fibromyalgia concept. The author applies himself to describing how the profile of this syndrome, associating chronic widespread pain to allodynia, became more and more precise, until it obtained the status of disease. He emphasizes that the concept lost its initial meaning when the criteria, resulting from an ambitious scientific methodology, were used to establish a diagnosis on an individual scale. He comes to the conclusion that after a century of existence, fibromyalgia does not possess any specific quality that would distinguish it from other chronic widespread pain syndromes to make it a pure nosological entity. It is an artificial construct that adds nothing to the understanding of a pain phenomenon and allows no rational therapeutic approach.

[Polymyalgia rheumatica and pulmonary cancer: paraneoplastic syndrome]. / Polymyalgia rheumatica et cancer pulmonaire: syndrome paranéoplasique.

An 83-year-old lady was admitted for bilateral pain and weakness of the shoulder and hip girdles. These symptoms suggested a Polymyalgia rheumatica (PMR) but there was no response to corticosteroids. A pulmonary adenocarcinoma without any metastasis was then diagnosed. The excision of this tumor was followed by prompt and complete recovery. The erythrocyte sedimentation rate became normal within a few days, also. Such an issue seems to prove that PMR may occasionally be associated with neoplasia. This association appears anecdotal in the literature and remains without clear explanation.

[Fractures due to bony insufficiency of the sacrum]. / Fractures par insuffisance osseuse du sacrum.

Six cases of insufficiency fracture of the sacrum were diagnosed in the Rheumatic Diseases Division of the CHUV during 1990. They show that this recently described entity is frequent. Present knowledge of the clinical course, predisposing factors, radiological findings and treatment is reviewed. This diagnosis should be considered in all cases of lower back pain occurring in postmenopausal women. Awareness of this entity should make it possible to avoid unnecessary invasive investigations.

[Comparison of fructosamine and Hba1c for the evaluation of metabolic control of diabetic patients]. / Comparaison de la fructosamine et de l'HbA1c pour l'évaluation du contrôle métabolique du diabète.

Fructosamine values, and the influence thereon of age, BMI and sex, were determined in 384 nondiabetic individuals aged between 20 and 95 years. In this control group mean F levels were 2.45 +/- 0.25 mmol/l and were age-related only, rising from 2.3 in the second decade to 2.6 in the eighth. We compared F and HbA1c in 135 diabetic patients. F correlated with HbA1c in the diabetic group (r = 0.76, p less than 0.001). Because of its biological properties fructosamine could become a useful pointer in the metabolic follow-up of diabetic patients, especially where clinic visits are frequent.