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7/30/2019 Kuliah Osteoporosis Yarsi
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OSTEOPOROSIS
Dr. Zulfan, SpPD
Bagian Penyakit Dalam
FK Universitas YARSI
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Osteoporosis is a major public health problem, and
postmenopausal osteoporosis constitutes as a major part
of the problem.
Claus Christiansen, Am J Med 1993
Hip fractures will increase sharply in the next half
century, especially in Asia, making osteoporosis a trulyglobal issue.
WHO 1998
EPIDEMIOLOGY
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Introduction
Osteoporosis is a disease characterized
by low bone mass and microarchitecturaldeterioration of bone tissue, leading toenhance bone fragility and a consequentincrease in fracture risk
(WHO)
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Osteoporosis is a skeletal disorders
compromised bone strength,
predisposing in an increase risk
of fracture
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Rigg and Nelson divided into :
A/. Primary osteoporosis1. Post menopause osteoporosis
2. Senile osteoporosis
B/. Secondary osteoporosisOsteoporosis due to other condition
of disease such as metabolic,endocrine or malignancy
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Post menopausal osteoporosis
Most common in woman 15 20 year after menopause
Mostly affects trabecular bone, increasing patient
susceptibility to vertebral compression fractures,
distal radial fractures and intertrochanteric fractures.
Esterogen deficiency plays a primary role
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Senile Osteoporosis Occurs in men and women over the age of
70 years with female to male ratio of 2:1
It affects : cortical and trabecular boneequally, predisposing patient to multiplewedges vertebral and femoral neck
fracturesAging and long-term calcium deficiency is
more important.
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Primary osteoporosis mostly are old and
elderly people complaining of mild
backache but may also a sudden pain
with only a mild injury due to a
compression fractures of the vertebrae.
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Before it reaches the threshold of fractures,
usually the height of patient reduces beside
deformity (kyphotic deformity)
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It is a silent disease, meaning there is
no significant signs and symptoms
caused by osteoporosis
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Etiology :
General factor predictive of osteoporosis :
1. Peak bone mass at maturity :
General / familialNutritionalPhysical (activity status, exercise, etc)Life style (alcohol, cigarettes, caffeine)
Medical (chronic disease, hypogonadal states, etc)Iatrogenic (corticosteroid, anticonvulsant, etc)
Orthopaedics Study Guide, Metabolic Bone Disease, 1999, p.885-889
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20 40 8060
BoneMass
Peak Bone Mass
male
female
Menopause
Bone Loss
Bone Mass Development
ageAge (year)
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2. Post menopausal bone loss
Accelerated trabecular bone loss for 3to 10 years post menopausal
Due to increased bone resorptionsecondary to estrogen loss
Loss of normally 1 to 2% per year to
a maximum of 10%
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
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3. Age-related (involutionall) bone loss
Starts at age 35 40 years in both sexes,continues for 30 to 40 years
Subtle uncoupling of rates of bone formationand resorption
Both cortical and trabecular bone affectedLoss normally less than 0.5% per year to a
maximum of 20 %
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
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Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
4. Risk factors
Genetic, life style, Medical, Iatrogenic
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Risk factors for bone loss :
1. Genetic :
- Female sex- Caucasian / Asian ethnicity- Family history of osteoporosis
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
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2. Life Style :
- Low calcium intake- Excessive alcohol use
- Cigarette smoking- Excessive caffeine use- Extreme or insufficient athlecity- Excessive acid ash diet (high protein /
soft drink intakes)
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
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3. Medical :
- Early menopause- Gonadal hormone deficiency states
- Eating disorders- Chronic liver / kidney disease- Malabsorption syndrome
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
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4. Iatrogenic :- Corticosteroids- Excessive thyroid hormone
- Chronic heparin therapy- Radiotherapy to skeleton- Long-term anticonvulsants
- Loop diuretics
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
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Bone is the most dynamic tissue.
Metabolism of catabolism and anabolism
as the activity of osteoclast and osteoblast
as a process of bone remodeling or
bone turn over
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Degeneration occurs as an aging process
where the activity of osteoclast is not able
to compensate by the activity of osteoblast.
As a result bone mineral density decrease
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The main problem of osteoporosis
lies in the effectiveness of intervention-prevention and treatment
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Osteoporosis is preventable if prevention
starts during the childhood and adolescence
when bone reaches maturity at the end
of 3rd decade to achieve maximum
Peak Bone Mass
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After the 3rd decade all organ include skeletal /bone will degenerate, the speed ofdegeneration, differs for different organ.
In general organ will loose function
1% every year (the rule of 1% of Andreas
and Tobin)
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Diagnosis should include differential diagnosis ofprimary and secondary osteoporosis by :
o Taking a good history
o Physical examination
o Laboratory examination
o Imaging examination
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DIAGNOSIS
History :
o ras, sex and age
o health status
o life style (alcohol, smoking)
o physical activity (sports)
o history of previous disease including administration of
drugs, previous fracture.
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Physical Examination :
Body weight and height (BMI)
Extremities and spine including :
deformity, MMT and ROM
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Laboratory findings :
o blood serum
o hormone
o Urine
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LABORATORY FINDINGS :
Routine:
- Serum :- Complete blood counts
- Electrolytes, creatinine, blood urea, nitrogen calcium
- Phosphorus, protein, albumin, alkaline phosphatase,
liver enzyme
- Protein electrophoresis
- Thyroid function tests
- Testoterone (men only)- 24 hours urine :
- calcium
- Pyridinium cross-links
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LABORATORY FINDINGS :
Spesial :
- Serum:
- 25 hydroxyvitamin D3
- 1,25 hydroxyvitamin D3
- intact parathyroid hormone
- osteocalcium (bone Gla protein)
- Urine :
- Immunoelectrophoresis
- Bence-Jones protein
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IMAGING :Radiology : plain X-ray
(especially the spine, hip and wirst)
The spine : - the ballooning disc
- deformity of vertebral body
(wedge, fish tail)
The Hip : - Singh Index
The Wirst : - Porotic / thinning cortex
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The general diagnostic categories
established in woven : (WHO working group)
Normal : Bone Mass Density (BMD)or
Bone Mineral Content (BMC)-1 SD from T Score of the young
adult reference mean
Osteopenia : BMD or BMC 1 SD to 2.5 SD
Osteoporosis : BMD or BMC
2.5 SD
(severe osteoporosis when there is followed a fracture)
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Prevention and Treatment
T-score Fracture risk Teatment
> +1 very low no treatment densitometry with indication
-1 s/d 0 low no treatment densitometry after 5 years
- 1 s/d +1 low no treatment densitometry after 2 years
-1s/d -2,5 midle prevention densitometry after 1 years
< - 2,5 high osteoporosis treatment
no fracture continue prevention densitometry after 1 years
< - 2,5 very high osteoporosis treatmentWith fracture continue prevention
surgery with indication densitometry after within6 month1 years
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Prevention
Aging process is a natural process of a persongetting old
3 steps of osteoporosis prevention :I. Up to the end of 3rd decadewhere Peak Bone Mass should be achieved
II. After the 3rd decade up to menopause /Andropause
III. Senile, prevent from minor injury / accident
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Goal of Osteoporosis Prevention
Optimising skeletal developmentNutritionPhysical activityLife style changesMinimize medical / iatrogenic factors
Minimize postmenopausal bone loss
Early identification of patients at riskReduced risk factorsHormone replacement therapy (HRT)Other agents pre-emptively if HRT contraindicatedraloxifene, alendronate
Minimize age-related bone lossIdentification of patients at riskReduce risk factorsFull prevention and exercise program (physical therapy)
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
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1st Prevention :
Good nutrition
Life style and physical exercise
To achieve maximum Peak Bone Mass
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2nd Prevention
Early diagnose of osteoporosis The same prevention as 1st prevention In female patient after menopause with HRT Prevention of the use of medication
consist steroid etc
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3rd Prevention
Prevent from accident
(minor injury could cause fracture) Care giver especially after fracture Operative intervention and bracing
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Treatment
Nowadays there is a lot of medicationFor osteoporosis such as :- calcium and vitamin D- calcitriol- calcitonin
- bisphosphonate : generation : I
IIIsuch as (clorodronate, alendronate, and
risedronate (actonel))- hormone : - anabolic
- sex hormone
- SEMs (Selective Modulator)- SERM (Selective Estrogen Reseptor
Modulator : Raloxifene(analogue of tamosifene)
SURGERY
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Calcium : 1500 mg / day
Vitamin D : 500 mg / day
Calcitonin (myacalcic : Nasal spray: 200 mg / daily)
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HRT :establish approach for osteoporosis prevention
and treatment.
But what after WHI report ????
SERM :Raloxifene : Evista : 60 mg/daily
- the goal is to increase bone benefits and decrease
deletterious affects on breast and endometrim.
- decrease breast cancer : 76 %
- 60 % women, 2 years : BMD increase 1-2 %
Dr. C. Deeply
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DIET CUKUP KALSIUM DAN VIT. D4 SEHAT 5 SEMPURNA
KEBUTUHAN KALSIUM
Balita 400 700 mg / hari Remaja 1000 1500 mg / hari Dewasa 750 1000 mg / hari Hamil 1500 mg / hari Menyusui 2000 mg / hari Sebelum menopause 800 1000 mg / hari Selama menopause 1000 1200 mg / hari Setelah menopause 1200 1500 mg / hari
BAHAN MAKANAN
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BAHAN MAKANAN
Per Ons Teri nasi mengandung 1000 mg Kalsium
Per Ons Kepiting 210 mg
Per Ons Kerang 133 mg
40 gr Dencis kaleng 200 mg
Per Ons Kuning telur ayam 147 mg
Per Ons Tempe 129 mg
Per Ons Tahu 124 mger Ons Emping 100 mg
Per Ons Bayam merah 347 mg
Per Ons Kacang panjang 347 mg
Per Ons Daun singkong 165 mg
1 gelas Susu kental manis 275 mg1 gelas Susu segar 380 mg
1 gelas susu krim penuh 290 mg
1 gelas Susu non fat 480 mg
1 gelas yurgort 200 mg
20 gr keju 100 mg
PREPARAT KALSIUM YANG TERSEDIA DI PASARAN
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PREPARAT KALSIUM YANG TERSEDIA DI PASARAN
No. Jenis Kalsium Nama Dagang Kalsium(mg)
1. Kalsium karbonat Ca-C 100 Sandoz 327
Calsan 1250
Caxon-F 250
Calsium Sandoz 300
Epocaldi 400
2. Kalsium Laktas Ca-C 1000 Sandoz 1000
Calcidin 100
Calsium Sandoz 2940
3. Kalsium fosfat Calcidin 200
Calcalcin 800
Catatan : Kalsium karbonat mengandung 40 % kalsium
Kalsium laktas mengandung 13 % kalsium