Left/right hip DXA plus steroids and osteoporosis
Osteoporos Int. 2006 Sep 20; [Epub ahead of print] The prevalence of significant left-right differences in hip bone mineral density. Hamdy R and others. PMID: 17019523. This is a complex study involving dual-energy X-ray absorptiometry (DXA) to try to find out if there could be a failure to diagnose osteoporosis when only one hip is scanned in the DXA. The authors conclude that, “A statistically significant number of women with osteoporosis are potentially classified differently when scanning only one hip as a result of the high prevalence of left-right differences in BMD.” Editor's comments: In summary, this study shows that if your DXA only scans one hip, you are at a statistically significant risk of not properly being diagnosed when you have osteoporosis. Although only women were tested in the study, the results would apply equally to men or women. Patients have only one option to eliminate the possibility of one hip having significantly different bone mineral density (BMD) than the other, to ask that their DXA be done with a machine that scans both hips. This might mean going to another diagnostic center to have the test done, but it could be important and worth the effort. I suggest discussing this with your care provider to see if he/she can refer you to a facility that uses a dual-hip scanning machine.
J Clin Rheumatol. 2006 Oct;12(5):221-5. Prevalence of evaluation and treatment of glucocorticoid-induced osteoporosis in men. Cruse LM and others. PMID: 17023807. It has been known for many decades that corticosteroids, such as prednisone, cause a loss of BMD when used in high doses for long periods. This study was done to see if men receiving prednisone for any reason during a six-month period at the James A. Haley Veterans Affairs Hospital, Tampa, FL were receiving assessment and therapy for the prevention and treatment of glucocorticoid-induced osteoporosis. Please read the abstract to see the details of the number of men in the study and what parameters were tested. The authors concluded, “Bone mineral density testing was performed or ordered for less than half of the glucocorticoid-treated patients and less than one third were taking bisphosphonate therapy.” Editor's comments: I have reported the results of similar studies on this site several times. The findings are disheartening because, as they say, this isn't rocket science. If you give corticosteroids in high doses (7.5 mg or more prednisone equivalent per day) for long periods (more than three months), you have to diagnose and treat the person for osteoporosis. Actually, you have to take preventive measures to preclude the loss of BMD in these individuals if you know in advance their therapy will be high-dose for an extended period. And you have to do a DXA to have a picture of the patient's initial BMD. This means that 100% of long-term high-dose steroid therapy patients must have a baseline DXA and need some form of osteoporosis prevention therapy. This simplifies the options—in fact removing all other possibilities—thus giving care providers no wiggle room for not doing their job. If there were gray areas, it would be easy to forgive improper diagnosis and treatment when long-term high-dose corticosteroids therapy was instituted, but there are no gray areas. Rheumatology got the best result in this study with a 75% passing grade while primary care flunked with only 30% of their patients receiving proper diagnosis and treatment. Unfortunately this means that 25% of the specialty care patients were improperly diagnosed and treated, not exactly stellar, but certainly better than how primary care performed. Therefore patients have to educate themselves about the dangers of long-term high-dose steroids. If not, they are at potentially very high risk of osteoporosis to accompany the condition for which they are receiving the steroids.