The role of bone mineral density in therapeutic decision-making using the Fracture Risk Assessment Tool (FRAX): a sub-study of the Taiwan OsteoPorosis Survey (TOPS).

Fracture Risk Assessment Tool (FRAX)-based intervention threshold (IT) is widely applied for treatment decision-making; however, an IT based on FRAX without the measurement of bone mass density (BMD) has not been validated. The study demonstrated that estimates of fracture risk by FRAX without BMD were higher than those by FRAX with BMD in women with old age. INTRODUCTION: BMD is an integral component for bone strength assessment, but age-specific impacts of BMD on fracture risk assessment and therapeutic decision-making remained unclear. We aimed to investigate whether using BMD measurement changed the interpretation of the FRAX-based fracture probability assessment and treatment decision. METHODOLOGY: The database was provided by the Taiwanese Osteoporosis Association (TOA) which conducted a nationwide survey of BMD. We calculated the 10-year major and hip fracture probabilities using the FRAX for each participant, either with (FRAX + BMD) or without BMD (FRAX - BMD). Age-specific individual intervention thresholds (IITs) were established using the FRAX-based fracture risk, equivalent to a woman with a prior fracture. Participants whose FRAX scores of major fracture were greater than or equal to their IITs were deemed suitable for therapeutic intervention. RESULTS: A total of 14,007 postmenopausal women were enrolled. Compared with FRAX + BMD, FRAX - BMD predicted lower FRAX scores in major and hip fractures in subjects aged 40-60 years; however, FRAX - BMD estimated higher risks for those aged 61-90 years. The therapeutic decision using FRAX - BMD was concordant to that using FRAX + BMD in 90.5% of the subjects, especially in the younger age group (40-70 years). FRAX - BMD identified more treatment candidates (7.7-16.4%) among those aged 71-90 years. CONCLUSIONS: The FRAX scores are influenced by age, irrespective of the consideration of BMD. FRAX - BMD is able to identify more subjects for therapeutic intervention in the elderly population. We should reconsider the role of BMD at different ages for therapeutic decision-making.

Assessment of glomerular filtration rate based on alterations of serum brain-derived neurotrophic factor in type 2 diabetic subjects treated with amlodipine/benazepril or valsartan/hydrochlorothiazide.

BACKGROUND: Brain-derived neurotrophic factor (BDNF) is associated with sympathetic activation. However, the effects of BDNF on diabetic nephropathy are unknown. The aim of this study was to assess the estimated glomerular filtration rates (eGFRs) and changes in serum BDNF levels in type 2 diabetic subjects treated with antihypertensive medications. METHODS: In this randomized, double-blind clinical trial, type 2 diabetic subjects with hypertension were assigned to either the benazepril/amlodipine or valsartan/hydrochlorothiazide treatment groups for a 16-week period. The post hoc analyses were based on increased or decreased serum BDNF levels. RESULTS: Of the 153 enrolled subjects, the changes in eGFR were significantly and inversely correlated with those in BDNF in the 76 subjects treated with valsartan/hydrochlorothiazide (r = -0.264, P = 0.021) but not in the 77 subjects treated with benazepril/amlodipine (r = -0.025, P = 0.862). The 45 subjects with increased BDNF following valsartan/hydrochlorothiazide treatment exhibited a significantly reduced eGFR (-8.8 ± 14.9 mL/min/1.73 m(2); P < 0.001). Multivariate regression analysis revealed that increased serum BDNF represents an independent factor for reduced eGFR (95% confidence interval between -0.887 and -0.076, P = 0.020). CONCLUSIONS: Increased serum BDNF is associated with reduced eGFR in type 2 diabetic subjects treated with valsartan/hydrochlorothiazide but not with amlodipine/benazepril.

Incidence and prevalence rates of diabetes mellitus in Taiwan: analysis of the 2000-2009 Nationwide Health Insurance database.

BACKGROUND/PURPOSE: Formerly, Taiwan's diabetic population has been estimated by surveys conducted at irregular intervals and using different sampling methods. To obtain nationwide data on the incidence and prevalence of diabetes mellitus (DM) in Taiwan, we performed an analysis of the 2000-2009 claim data from the National Health Insurance (NHI) database. METHODS: One-third of the claims in the NHI database from 2000 to 2009 were randomly sampled. DM was defined by three or more outpatient visits with diagnostic codes (ICD-9-CM: 250 or A code: A181) within 1 year or by one inpatient discharge diagnosis of DM. Confirmation of type 1 diabetes mellitus was based on the issue of a catastrophic illness certificate with the same diagnostic codes. Age and/or gender distribution for DM were determined. RESULTS: In accordance with the global trend for DM, with a near constant standardized incidence rate, there was a more than 70% increase in the total diabetic population, or a 35% increase in the standardized prevalence rate, in Taiwan from 2000 to 2009. The incidence of diabetes was higher in men, especially in the 20-59-year-old age group, and the total number of men with diabetes exceeded the number of women with diabetes in 2005. However, the prevalence and incidence rates in women over the age of 60 years were higher than those in men. Type 1 DM was present in less than 1% of the diabetic population in Taiwan. CONCLUSION: The incidence of diabetes, including type 1, remained stable over this 10-year period in Taiwan. However, the incidence rate in men aged 20-59 years was higher than that in age-matched women. With our nationwide database, subgroup analysis of DM incidence can be performed to refine our health policies for the prevention, screening, and treatment of diabetes mellitus.

Osteoporosis treatment in postmenopausal women with pre-existing fracture.

Osteoporotic patients with existing fractures are at substantially higher risk of subsequent fractures than those free of fractures. Given the lack of head-to-head comparison trials, indirect comparison of various antiosteoporosis treatments may be an alternative way to develop a preliminary idea. The objective of this study is to conduct a systematic review of antiosteoporosis treatment clinical trials that have investigated on patients with existing fractures. All the results of randomized placebo-controlled trials of the available antiosteoporosis treatments, including bisphosphonates, selective estrogen receptor modulators, calcitonin, strontium ranelate, and agents derived from parathyroid hormone, on patients with existing fractures were summarized. All the antiosteoporotic agents had significant efficacy in increasing lumbar spine bone mineral density and reduction in the occurrence of any new vertebral fractures. All interventions provided gains in quality-adjusted life-years compared with patients without treatment. The results from an indirect comparison must be interpreted with caution due to heterogeneous study design, discrepancies of disease severity at baseline, and differences in analytical methodologies. The devastating complications subsequent to osteoporotic fractures create medical and financial burdens; therefore, treatment of patients with osteoporotic fractures should be positioned in the top priority in the utilization of medical resources.