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RRRRCC
OSTEOPOROSISOSTEOPOROSIS
Rheumatology Research Center
INTERNAL MEDICINE CONGRESS 1382INTERNAL MEDICINE CONGRESS 1382INTERNAL MEDICINE CONGRESS 1382INTERNAL MEDICINE CONGRESS 1382
RRRRCCRRRRCC
RRRRCC
DEFINITIONDEFINITION
• Systemic Skeletal Disease • Low Bone Mass • Micro Architectural Deterioration
– Increase in Bone Fragility– Susceptibility to Fracture Am J Med 1993;94:644-650
• Bone Densitometry– t score: –2.5SD
WHO 1990
• Systemic Skeletal Disease • Low Bone Mass • Micro Architectural Deterioration
– Increase in Bone Fragility– Susceptibility to Fracture Am J Med 1993;94:644-650
• Bone Densitometry– t score: –2.5SD
WHO 1990
RRRRCC
EPIDEMIOLOGYEPIDEMIOLOGY
RRRRCC
EPIDEMIOLOGYEPIDEMIOLOGY
• USA (NHANESS III 1997)
– Women 13 - 18%
– Men 1 - 4%
• IRAN 4,575,000 - 7,150,000
• USA (NHANESS III 1997)
– Women 13 - 18%
– Men 1 - 4%
• IRAN 4,575,000 - 7,150,000
RRRRCC
FRACTURE RISK50 YEARS AND OVER
FRACTURE RISK50 YEARS AND OVER
WOMEN MEN
• Femur 17.5% 6.0%
• Spine 15.6 5.0
• Wrist 16,0 2.5
• Any Fracture 39.7 13.1
WOMEN MEN
• Femur 17.5% 6.0%
• Spine 15.6 5.0
• Wrist 16,0 2.5
• Any Fracture 39.7 13.1
RRRRCC
BONE PHYSIOLOGY
BONE PHYSIOLOGY
RRRRCC
BONE PHYSIOLOGYBONE PHYSIOLOGY
• Bone Resorption
– Osteoclast
• Bone Formation
– Osteoblast
• Bone Remodeling
Unit
– Positive < age 30
– Negative > age 30
• Bone Resorption
– Osteoclast
• Bone Formation
– Osteoblast
• Bone Remodeling
Unit
– Positive < age 30
– Negative > age 30
00.10.20.30.40.50.60.70.80.9
1
10 15 20 25 30 35 40 45 50 55 60 65 70 75
RRRRCC
OSTEOBLASTOSTEOBLAST
• Origin: Mesenchymal Cell
• Activation: PTH, Vitamin D
• Function
– Matrix Formation
– Bone Mineralization
– Matrix Degradation RANK L
• Origin: Mesenchymal Cell
• Activation: PTH, Vitamin D
• Function
– Matrix Formation
– Bone Mineralization
– Matrix Degradation RANK L
RRRRCC OSTEOCLASTOSTEOCLAST
• Origin– Blood Mononuclear Cells
• Differentiation
– CSF-1
– RANK L• Lymphocyte
• Osteoblast
• Action– Acidification
– Protein Degradation
• Origin– Blood Mononuclear Cells
• Differentiation
– CSF-1
– RANK L• Lymphocyte
• Osteoblast
• Action– Acidification
– Protein Degradation
H2O + CO2
HCO3
H+
Cl
RRRRCC
BONE REMODELING UNITBONE REMODELING UNIT
. . . ... . . .. . . .
. . . . . .
Resorption Formation Completion
RRRRCC
STIMULATION
IL-1TNF-IL-6IL-11
PTHVit D
RANK
BONE RESORPTIONBONE RESORPTIONM-CSF
IL-1TNF-IL-6IL-11
PTHVit D
RANKSTIMULATION
RRRRCC
STIMULATION
PROGESTERONE
ANDROGEN
ILGF PTHVit D
ESTROGEN
ESTROGEN
STIMULATION
CALCITONIN
INHIBITION
COUPLING FACTOR
IL-1TNF-IL-6IL-11
INHIBITION
PTHVit D
RANK
BONE FORMATIONBONE FORMATION
RRRRCC
CLINICAL MANIFESTATIONS
CLINICAL MANIFESTATIONS
RRRRCC
CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS
• Symptoms Non
• Complications Fractures
– Macroscopic
• Vertebra
• Femoral Neck
• Wrist
• Others
– Microscopic
• Vertebrae: Mechanical Pain, Spine Deformity
• Symptoms Non
• Complications Fractures
– Macroscopic
• Vertebra
• Femoral Neck
• Wrist
• Others
– Microscopic
• Vertebrae: Mechanical Pain, Spine Deformity
RRRRCC
DIAGNOSISDIAGNOSIS
RRRRCC
OLD DAYSOLD DAYS
RRRRCC
20th CENTURY20th CENTURY
• X-RAY
• BONE BIOPSY
• X-RAY
• BONE BIOPSY
RRC
RRRRCC
NOWADAYSNOWADAYS
BONE DENSITOMETRYBONE DENSITOMETRY
RRRRCC Dual Energy X-ray Absorptiometry
(Gold Standard)
Dual Energy X-ray Absorptiometry
(Gold Standard)
• NON INVASIVE
– Irradiation: 1/100 Chest X-ray
– 1 h. Sun Exposure
• SENSITIVITY 1.0%
• ACCURACY 2.8%
• REPEATABLE
• LONGITUDINAL STUDY
• NON INVASIVE
– Irradiation: 1/100 Chest X-ray
– 1 h. Sun Exposure
• SENSITIVITY 1.0%
• ACCURACY 2.8%
• REPEATABLE
• LONGITUDINAL STUDY
RRRRCC
BONE MINERAL DENSITYBONE MINERAL DENSITY
• SPINE
• FEMUR
• FOREARM
• OTHERS– Whole Body
– Heel
– hand
• SPINE
• FEMUR
• FOREARM
• OTHERS– Whole Body
– Heel
– hand
RRRRCC
RESULTRESULT
• BMD 0.857
• Comparison To Young Adult
– % 76%
– t Score -2.4
• Comparison To Same Age
– % 101%
– z Score+0.1
• BMD 0.857
• Comparison To Young Adult
– % 76%
– t Score -2.4
• Comparison To Same Age
– % 101%
– z Score+0.1
RRRRCC SPINESPINE
RRRRCC SPINESPINE
RRRRCC FEMURFEMUR
RRRRCC FEMURFEMUR
RRRRCC FOREARMFOREARM
RRRRCC FOREARMFOREARM
RRRRCC
DIFFERENT STANDARDSDIFFERENT STANDARDS
• COUNTRIES and ETHNICITIES
• MACHINES
– Hologic
– Lunar
– MediLink
– Norland
• COUNTRIES and ETHNICITIES
• MACHINES
– Hologic
– Lunar
– MediLink
– Norland
RRRRCC AMERICAN STANDARDAMERICAN STANDARD
400
500
600
700
800
900
1000
1100
1200
20 30 40 50 60 70
400
500
600
700
800
900
1000
1100
1200
20 30 40 50 60 70
Standardized BMD
PBM1124 mg
1006 mg
829 mg
Osteopenia
Osteoporosis
Female - SpineFemale - Spine
RRRRCC IRANIAN STANDARDIRANIAN STANDARD
400
500
600
700
800
900
1000
1100
1200
20 30 40 50 60 70
400
500
600
700
800
900
1000
1100
1200
20 30 40 50 60 70
Standardized BMD
PBM1097 mg Female - SpineFemale - Spine
RRRRCC COMPARISONCOMPARISON
400
500
600
700
800
900
1000
1100
1200
20 30 40 50 60 70
400
500
600
700
800
900
1000
1100
1200
20 30 40 50 60 70
Standardized BMD
PBM diff2.5%
1006 mg
829 mg
Osteopenia
Osteoporosis
Female - SpineFemale - Spine
RRRRCC
DEFINITIONSDEFINITIONS
• NORMAL BONE
– 1.0 to -1.0 SD over/bellow PBM
• OSTEOPENIA
– -1.0 to -2.4 SD bellow PBM
• OSTEOPOROSIS
– -2.5 SD bellow PBM
• NORMAL BONE
– 1.0 to -1.0 SD over/bellow PBM
• OSTEOPENIA
– -1.0 to -2.4 SD bellow PBM
• OSTEOPOROSIS
– -2.5 SD bellow PBM
RRRRCC BMD REPORTBMD REPORT
• FRACTURE RISK Spine Neck
– t = -1 SD 2.2 2.6
– t = -2 SD 5.0 7.0
– t = -3 SD 11.0 18.0
• Comparison Iranian Standard
• Advice
– Evaluation
– Prevention/Treatment
• FRACTURE RISK Spine Neck
– t = -1 SD 2.2 2.6
– t = -2 SD 5.0 7.0
– t = -3 SD 11.0 18.0
• Comparison Iranian Standard
• Advice
– Evaluation
– Prevention/Treatment
RRRRCCPURPOSE and APPLICATIONPURPOSE and APPLICATION
• DIAGNOSIS
– Osteoporosis
– Osteopenia
– Normal Bone
• CALCULATION
– Time to Osteopenia
– Time to Osteoporosis
• DIAGNOSIS
– Osteoporosis
– Osteopenia
– Normal Bone
• CALCULATION
– Time to Osteopenia
– Time to Osteoporosis
RRRRCC BONE LOSSBONE LOSS
0.53
0.85
1.02 1.05
0.9
0.5
0
0.2
0.4
0.6
0.8
1
1.2
35-40 40-45 45-50 50-55 55-60 60-65
0.53
0.85
1.02 1.05
0.9
0.5
0
0.2
0.4
0.6
0.8
1
1.2
35-40 40-45 45-50 50-55 55-60 60-65
%
Age
22% Loss 35-65 Y
Spine – Iranian Women
RRRRCC INDICATION(People at Risk)
INDICATION(People at Risk)
• Menopause
• Inflammatory Diseases
• Endocrine Disorders
• Predisposing Drugs
• Familial History
• Fracture
• Menopause
• Inflammatory Diseases
• Endocrine Disorders
• Predisposing Drugs
• Familial History
• Fracture
RRRRCC
BONE TRABECULABONE TRABECULA
RRRRCC
BONE TRABECULABONE TRABECULA
RRRRCC
RRRRCC
BONE TRABECULABONE TRABECULA
RRRRCC
PREVENTIONPREVENTION
RRRRCC
PREDISPOSING FACTORSPREDISPOSING FACTORS• Genetic
– Stature
– Vitamin D Receptor: DD, Dd, dd
• Alimentation– Calcium, Protein
• Physical Activity• Habits
– Coffee, Alcohol, Smoking
• Disease– Endocrine, Inflammatory Diseases, Renal Disorders
• Drugs– Steroids, Cytotoxic, Anti-epileptic, Heparin, Thyroxine
• Genetic– Stature
– Vitamin D Receptor: DD, Dd, dd
• Alimentation– Calcium, Protein
• Physical Activity• Habits
– Coffee, Alcohol, Smoking
• Disease– Endocrine, Inflammatory Diseases, Renal Disorders
• Drugs– Steroids, Cytotoxic, Anti-epileptic, Heparin, Thyroxine
RRRRCC PREVENTION(Normal Person, Normal BMD)
PREVENTION(Normal Person, Normal BMD)
• Young– Alimentation
– Sport
• Mid Age (up to menopause)
– Habits
• Menopause– HRT (Allendronate?), Calcium, Exercises
• Senile– Exercises
• Young– Alimentation
– Sport
• Mid Age (up to menopause)
– Habits
• Menopause– HRT (Allendronate?), Calcium, Exercises
• Senile– Exercises
RRRRCC
PREVENTION(Disease or Medication, Normal BMD)
PREVENTION(Disease or Medication, Normal BMD)
• Same as for Normal Person
• Adequate Management of the Disease
– Minimum Required Dose of Predisposing Drug
• Medication
• Calcium
• Exercise
• Same as for Normal Person
• Adequate Management of the Disease
– Minimum Required Dose of Predisposing Drug
• Medication
• Calcium
• Exercise
RRRRCC
RRRRCCDRUGSDRUGS
• Bone Forming– Synthetic PTH
– Fluoride 20-40 mg/daily + Ca + Vit
D
– Progesterone
– Anabolic agents Nandrolone Decanoate
• Resorption Preventing– Estrogen & Analogs ERT, HRT, Ralloxiphen
– Calcitonin Injectable, Nasal Spray
– Bisphosphonate Etidronate, Allendronate
• Bone Forming– Synthetic PTH
– Fluoride 20-40 mg/daily + Ca + Vit
D
– Progesterone
– Anabolic agents Nandrolone Decanoate
• Resorption Preventing– Estrogen & Analogs ERT, HRT, Ralloxiphen
– Calcitonin Injectable, Nasal Spray
– Bisphosphonate Etidronate, Allendronate
RRRRCC
ALLENDRONATEALLENDRONATE
• Osteofos
• Prevention– 5 mg daily
• Treatment– 10 mg daily
• Precautions– 30 Minutes Before Breakfast
– Upright Position
• Side Effects
• Osteofos
• Prevention– 5 mg daily
• Treatment– 10 mg daily
• Precautions– 30 Minutes Before Breakfast
– Upright Position
• Side Effects
RRRRCC INTERNAL MEDICINE CONGRESS 1382
Rheumatology Research Center
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