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This article appears in the following Rheumatology issue: Management of Osteoporosis: A Physiological Answer for a Living Tissue. Proceedings of a satellite symposium held on the occasion of the EULAR Congress, Paris, France, June 13, 2008. The symposium and these proceedings were made possible by an unrestricted educational grant from Servier [View the issue table of contents]
Introduction
Rheumatology Department, Paris Descartes University, Cochin Hospital, Paris, France
Correspondence to: C. Roux, Rheumatology Department, Paris Descartes University, Cochin Hospital, Paris, France. E-mail: christian.roux{at}cch.ap-hop-paris.fr
Osteoporosis is a progressive systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, increasing the risk of low-trauma fractures. Hip fractures are the most devastating consequences of osteoporosis, with an increase in mortality, and a loss of independence in daily living activities in a large proportion of survivors. The consequences of vertebral fractures are now recognized, although the majority of them do not come to clinical attention at the time they occur. Recurrent vertebral fractures are responsible for chronic back pain, thoracic hyperkyphosis, height loss, reduced physical function and decreased quality of life. Moreover, non-hip, non-spine fractures—which are the most frequent fractures—are the greatest cause of disability in people in their sixties.
Thus, beyond the diagnosis of osteoporosis, which is based on BMD measurement, the objective of osteoporosis management is the recognition of subjects at high risk for fracture. Prevalent fractures, including wrist and peripheral fractures, are common missed opportunities to identify patients at high risk of sustaining subsequent fractures. But other risk factors (family history of fracture, low BMI, risk of falls, underlying disease, as RA, current or past use of corticosteroids, etc.) provide relevant information to identify women who could benefit from a therapeutic intervention. In the near future, it is highly probable that techniques other than dual energy X-ray absorptiometry, which assess intrinsic bone parameters, as micro-architecture and cortical characteristics, will help physicians to assess fracture risk appropriately and design therapeutic strategies tailored to individual patients.
Bone is a living tissue, and more and more is known about determinants of bone remodelling and bone cell activity. Osteoblast and osteoclast interactions are now well known. The ‘third cell’—the osteocyte that till now has been neglected—is likely to have an important role. Of particular interest are the effects of other cells, as dendritic cells and T lymphocytes, and their cytokines on bone cell activity. All these topics are under investigation in the search for keys to controlling bone resorption and formation. The ideal treatment should improve bone strength and bone quality, thereby decreasing its propensity to fracture following minor trauma. Clinical studies have shown that it is possible to obtain this result by decreasing bone resorption (bisphosphonates, selective oestrogen receptor modulators), improving bone formation (parathyroid hormone) or both (strontium ranelate). In the near future, appropriate treatment sequences must be elaborated to ensure careful treatment and preservation of bone tissue.
This issue provides updated data on bone structure and bone assessment, as well as a review of efficacy and safety of strontium ranelate. It is hoped that this will help clinicians in their own approach to the management of osteoporotic patients.
Disclosure statement: C.R. has received grants and research support from Servier.
Accepted 1 April 2008
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