Der Internist
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Fracture risk cannot be determined by bone density alone. It is important to identify and consider risk factors that individually increase the risk of fractures when they occur. Risk calculators have been developed worldwide to determine fracture risk. ⋯ The threshold for diagnostics is reached with the presence of a risk factor mentioned in the guideline. To reach the threshold for therapy, the bone density measurement result is required to reach the age-specific T‑score. However, typical fragile fractures of the vertebral bodies or femur increase the fracture risk so substantially that therapy can be recommended even without a bone density result.
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Multiple myeloma (MM) is one of the most frequent cancerous diseases of the hemopoietic system. Over the past 60 years the systemic treatment has undergone multiple changes, from alkylating agents to high-dose therapy followed by autologous peripheral blood stem cell transplantation up to immunomodulating substances and proteasome inhibitors. The treatment of MM is currently undergoing a renewed transition. ⋯ Using MRI focal lesions can be detected even before bone destruction. In this year chimeric antigen receptor (CAR) T cell treatment of MM will be approved for the first time in Germany. Novel antibody constructs, such as belantamab mafodotin, are or will be introduced for a late recurrence.
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The need for a long-term pharmacological treatment of osteoporosis, the problem of potential compliance issues and also potentially severe side effects during the treatment are of central interest not only for patients but also for medical guidelines and prescribers. This review summarizes the current knowledge about the pharmacological substances used and the current scientifically based guidelines and approaches for the long-term use as well as the monitoring and potential treatment changes with a special focus on future developments.
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Delineating the genetic background and the underlying pathophysiology of rare skeletal dysplasias enables a broader understanding of these disorders as well as novel perspectives regarding differential diagnosis and targeted development of therapeutic approaches. Hypophosphatasia (HPP) due to genetically determined Alkaline Phosphatase deficiency exemplifies this development. While an enzyme replacement therapy could be established for severe HPP with the prevailing bone manifestation, the clinical impact of not immediately bone-related manifestations just being successively understood. ⋯ Evolutions regarding the nosology of osteogenesis imperfecta (OI) along with the identification of further causative genes also detected in the context of genetically determined osteoporosis illustrate the pathophysiologic interrelation between monogenetic bone dysplasias and multifactorial osteoporosis. While current therapeutic strategies for OI follow osteoporosis treatment, the expanding knowledge about OI forms the fundament for establishing improved treatment strategies-for both OI and osteoporosis. Similar developments are emerging regarding rare skeletal disorders like Achondroplasia, Fibrodysplasia ossificans progressive and Morbus Morquio (Mukopolysaccharidosis Type IV).
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Osteoporosis is nowadays understood as an increased risk of fractures, with bone density measurement by dual-energy X‑ray absorptiometry (DXA) being a useful diagnostic criterion and a potent fracture predictor; however, especially in geriatric patients the result is often falsely negative, so that the diagnosis, indications for treatment and treatment selection should be based on an overall clinical evaluation of the individual situation. Sarcopenia is defined as a geriatric syndrome characterized by a generalized loss of skeletal mass and muscle function. Sarcopenia is associated with an increased likelihood of adverse outcomes including falls, fractures, disability and mortality. ⋯ In the case of a high fracture risk and indications for the presence of sarcopenia, the whole body composition should be assessed by DXA within the framework of the measurement of bone mineral density. In the treatment of osteosarcopenia non-pharmacological measures must be initiated in addition to pharmacological measures. It is particularly important to clarify and if necessary to resolve the cause of falls resulting in fractures as well as to regularly reevaluate the treatment goals.