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OSTEOPOROSIS

DR.DUAA HIASAT

Objectives :

To define osteoporosis.

To know the causes & risk factors of

osteoporosis.

To know when to screen for osteoporosis.

To talk about preventive measures of

osteoporosis.

To recognise general principles of

management.

What is osteoporosis??

A skeletal disorder characterised by decreased

bone strength ( density and/or quality) leading

to increased risk for fragility fracture.

Bones of hip,spine and wrist most commonly

affected.

Why is it important ??

Osteoporosis is a major public health problem,

which results in substational

morbidity,mortality and high costs.

Osteoporosis is an extremely serious disease

and is not part of the natural aging process.

Pathogenesis :

Maximum bone density is attained in young

adulthood. Women then typically lose 50% bone

mass over their remaining lifetime.

Bone loss begins in the premenopausal years &

accelerates in the early postmenopausal years.

Lack of estrogen causes a release of

osteoclastic inhibition leads to imbalance b/w

bone resorption and formation.

Causes of osteoporosis:

1 – Idiopathic age related osteoporosis (most

common).

2- Secondary osteoporosis.

Cont…

Osteoporosis secondary to disease states:

1. Metabolic conditions:

Ex: Calcium deficiency ,Vit.D deficiency,

Malnutrition,Idiopathic hypercalciurea,Scurvy.

2. Endocrine conditions :

Ex:Thyrotoxicosis,Cushings,Hypogonadism

Prolactinoma,HyperPTH,Hypoamenorrheic

female runners (Athletes triad).

3. Gastrointestinal disease:

Ex:IBD,Malabsorption (e.g Celiac sprue).

4. Bone marrow infiltration :

Ex: Lymphoma,Leukemia,Multiple myeloma.

5. Drugs :

Ex: Anticonvulsants,Thyroid hormones ,PPIs,SSRIs, Corticosteroids ( 7.5 mg/d/3 mo),GnRH agonists,

Chronic heparin/warfarin therapy,furosemide,Lithium.

6. Lifestyle:

Ex: Nutrition ,Alcohol,Smoking ,Immobilazion,

Inactivity.

7. Others : Rhematoid arthritis,COPD.

Organs involved

Trabecular bone more commonly affected than

compact bone.

Spine ( vertebral column),pelvis,hip ( femoral

neck),distal radius.

Who is at risk??

Majors risk factors for osteoporosis :

Age ≥ 65 years.

Gender ( more in females).

White or Asian race.

Menopausal status.

Personal history of fracture as an adult (esp. older than 45 years ; not including fingers,toes, and skull).

History of fragility fracture in a first-degree relative (esp.maternal hip fracture).

Current smoking.

Low body weight ( BMI <21 kg/m2).

Use of oral steroids > 3 months.

Additional risk factors:

Estrogen deficiency at an early age (<45

years).

Low physical activity.

Excessive alcohol (more than 2 drinks/day

Poor health.

Clinical manifestations of osteoporosis:

It’s usually asymptomatic until fracture occurs.

Loss of height is common.

Spontaneous fracture.

Collapse of vertebrae.

Diagnosis :

1- Based on bone densometry ( DEXA scan) with

the use of T or Z score.

2- Clinical diagnosis if fragility fracture regardless

of T/Z score.

Cont…

Central DEXA is the gold standard for assessment

of BMD.

-Two beams of different energy are directed at

The patient and the difference in absorption rate

by the patient body is recorded to quantify the

amount of BMD.

T and Z score

T–score is bone density expressed as number

of standard deviations above or below mean

BMD value for a normal young adult measured

by DEXA.

WHO criteria for diagnosis of bone status are :

T-score -1 is normal.

T-score between -1 and -2.5 is osteoponia.

T-score ≤ -2.5 is osteoporosis.

T-score ≤ -2.5 + fractue is sever osteoporosis.

CONT..

Z-score is bone density expressed as number of

SDs from normal mean value for age,sex and

ethnicity/race.

Z-score > -2 is normal.

Z-score ≤ -2 is osteoporosis.

In premenopausal women,men <50 years old,

and children,use Z-score instead of T-score.

When to do bone densometry??

National Osteoporosis Foundation (NOF)

recommends that all women 65 years should

be screened regardless of the presence or

absence of risk factors.

Younger postmenopausal women with one or

more risk factors (other than being

white,postmenopausal,and female) should also

be screened for osteoporosis.

U.S Preventive Services Task Force (USPSTF)

also recommends universal BMD screening for

all women ≥ 65 years and

for women ≥ 60 years if there are risk factors

for osteoporotic fractures.

In contrast to NOF, the USPSTF makes no

recommendation for or against routine

screening in postmenopausal women younger

than age 60 years or aged 60 to 64 years

without increased risk for osteoporotic

fracture.

Prevention:

It’s the least costly approach to osteoporosis

and should begin in youth .

Treatment : All patients being considered for pharmacologic

therapy should be counseled on the

importance of calcium,vitamin D,weight-bearing

exercise and fall preventive strategies to further

reduce their risk of fracture.

Before initiating pharmacologic treatment

patients should also be evaluated for

secondary causes of osteoporosis.

Who should be treated?

NOF recommends treatment for :

1. Patients with T-score below -2.

2. Patients with T-score below -1.5 if one or more

risk factors are present.

3. Patients who already have had osteoporotic

fracture (s).

Cont..

FDA – Approved therapeutic options

A) Prevention (stops bone loss) :

Estrogen.

Bisphosphonates ( Alendronate,Risedronate,

Ibandronate).

SERM (Raloxifne).

B) Treatment ( reduces spine fractures):

Calcitonin.

Parathyroid hormone.

Bishosphanates :

The most commonly used therapies for

osteoporosis.They are potent inhibitors of bone

resorption.

Alendronate was the first FDA-Approved drug ,

it’s taken orally 5 mg daily or 35 mg weekly for

prevention ,10 mg daily or 70 mg weekly for

treatment.

It reduces the incidence of vertbral and non-

vertebral fractures by about half.

Cont..

Because a minority of patients may suffer from

erosive esophagitis ,the patient should be advised to take it on empty stomach with water upon awakening ,remain upright ,and avoid food for 30 minutes afterwards.

Other Side effects:

GERD ( common).

Myalgia,arthralgia.

Jaw neck necrosis (rare but serious ).

Atrial fibrillation.

Estrogen:

Estrogen therapy alone or with a progestin is

indicated for the prevention of osteoporosis only.

However, because of the potential risks of

estrogen, the FDA recommends that if a woman

doesn’t have menopausal symptoms,

nonestrogen treaments should be carefully

considered before using estrogen therapy solely

for the prevention of postmenopausal

osteoporosis.

SERM:

It selectively binds to estrogen receptors and

inhibits bone resorption.

Raloxifene is FDA-Approved for both the

prevention and the treatment of osteoporosis.

Although Raloxifene decreases the risk of

vertebral fractures,there is no evidence that it

decreases the risk of nonvertebral fractures

including the hip.

How long should treatment continue?

It remains unclear whether anti-fracture

efficacy is sustained beyond 3-5 yrs.

Stopping treatment is followed by increased

remodeling,bone loss and further structural

damage.

Bone loss is likely to recur sooner after

cessation of HRT or raloxifene than

bisphosphonates.

When we should re-evaluate ??

It is generally recommended tht central DEXA

be repeated no less than 2 years from initiation

or change in drug therapy to detect significant

changes in BMD.

It is also important to note that drug therapy

may decrease fracture risk without an apparent

increase in BMD.

IN CONCLUSION

If BMD is > -1 SD do not treat.

If BMD is -1 to -2.5 SD treat if fracture is

present.

If BMD is <-2.5 SD treat whether or not a

fracture is present.

CASE 1

A 61-year old white postmenopausal woman

comes to your office for routine health

examination.She has a history of

osteoarthritis , she smokes 1 pack of cigarettes

Per day.She fractured her left wrist at age of 50

after falling down some stairs.Her diet is low at

calcium-rich food.She is on no medication except

calcium.Her physical examination is normal.

Q.1

You believe that she is at risk for osteoporosis the test of choice is ?

A.Ultrasound

B.Peripheral DEXA.

C.Central DEXA.

D.Plain X-ray.

E.Quantitative CT scan.

Q.2 You order a central DEXA scan to the patient and scan returns

with T score of -1.3 for the lumbar spine and -1.9 for the total

hip.What do you recommend to the patient at this time?

A.No action needed.

B.Repeat DEXA in 6 months.

C.Recommend adequate Ca intake, weight bearing exercise .

D.Recommend adequate Ca intake, weight bearing exercise and

bisphosphonates.

E.Recommend adequate Ca intake , weight bearing exercise and

calcitonin.

Q.3

Which of the following is not an established major

risk factor for osteoporosis?

A.Low body weight

B.Current smoking.

C.History of fragility fracture in 1st degree relative.

D.Low calcium intake.

E.Chronic use of steroids.

Q.4

Which of the following is in not an associated

risk factor for osteoporosis?

A.COPD

B.HyperPTH.

C.Cigarette smoking.

D.Obesity.

E.Excessive alcohol intake.

Q.5

What is the most common presenting fracture

in osteoporosis?

A.Wrist fracture (Colles fracture).

B.Vertebral compression fracure.

C.Femoral neck fracture.

D.Tibial fracture.

E.Femoral head fracture.

Q.6

Which of the following sites for osteoporotic

fracure is most commonly associated with

morbidity and mortality?

A.Ward’s triangle (hip).

B.Femoral neck ( hip).

C.Thoracic vertebrae (spine).

D.Lumbar vertebrae ( spine).

E.Distal radius (wrist).

Q.8

Which of the following is not recommended for

treatment of established osteoporosis?

A.Estrogen.

B.Calcium and Vitamin D.

C.Bisphosphonates.

D.SERMs.

E.Calcitonin.

Q.9

Which of the following studies may be indicated

in an asymptomatic patient recently diagnosed

with osteoporosis?

A.24-hr urine calcium.

B.Serum 25-hydroxy vitamin D.

c.PTH.

D.TSH.

E.All of the above.

CASE 2

A 32 years old woman is seeing because her mother as been diagnosed with osteoporosis.She asks you what type of exercise will help her prevent the development of the disease.According to the recommendations,which of the following excercises is most appropriate to help her maintain bone mass??

A.Tennis.

B.Swimming.

C.Cycling.

D.Skating.

E.Skiing.

CASE 3

You are treating an elderly postmenopausal woman with osteoporosis . She recently suffered an acute osteoporotic vertebral fracture and is suffering from secondary pain.Which of the following treaments alo has an analgesic effects with respect to bone pain?

A.Estrogen.

B.Combination of calcium & Vitamin D.

C.Calcitonin.

D.Alendronate.

E.Raloxifene.

CASE 4

You have just diagnosed osteoporosis in a postmenopausal woman.She is considering treatment alternatives and wonders about the bisphosphonates.Which of the following is the best description of how this class of medication works?

A.They increase calcium absorption in the GI tract.

B.They block the activity of the cytokines that stimulates bone reabsorption.

C.They bind to bone surfaces to inhibit osteoclast activity.

D.They stimulate osteoblasts and increase bone formation.

E.They mimic estrogen’s effect on bone.

Answers:

Case 1

Q1 c Q4 d Q7 a

Q2 d Q5 b Q8 a

Q3 d Q6 b Q9 e

CASE 2 answer is a

CASE 3 answer is c

CASE 4 answer is c

Thank you