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Osteoporosis Dr.S.Sethupathy

Defining Osteoporosis“Progressive systemic skeletal disease

characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk”

True Definition: bone with lower density and higher fracture risk

WHO: utilizes Bone Mineral Density as definition (T score <-2.5); surrogate marker

Who Gets Osteoporosis?AgeEstrogen deficiencyTestosterone deficiencyFamily history/geneticsFemale sexLow calcium/vitamin D intakePoor exerciseSmokingAlcohol

Who gets osteoporosis?Low body weight/anorexiaHyperthyroidismHyperparathyroidismPrednisone useLiver and renal disease (think about vit d

synthesis)Low sun exposureMedications (antiepileptics, heparin)Malignancies (metastatic disease;

multiple myeloma can present as osteopenia!)

Hemiplegia s/p CVA/ immobility

SYMPTOMS Back pain, which can be severe if fractured or collapsed

vertebra Loss of height over time, with an accompanying stooped

posture Fracture of the vertebrae, wrists, hips or other bones

Hypogonadal states • Turner syndrome, • Klinefelter syndrome, • Kallmann Syndrome, • anorexia nervosa, • hypothalamic

amenorrhea, • hyperprolactinemia.

Nutritional and gastrointestinal disorders

• malnutrition, • parenteral nutrition, • malabsorption

syndromes, • gastrectomy,• severe liver disease

(especially biliary cirrhosis),

• pernicious anemia. Hematologic disorders/malignancy

• multiple myeloma, • lymphoma and

leukemia, • mastocytosis, • hemophilia, • thalassemia.

Etiology

Endocrine disorders • Cushing's

syndrome, • hyperparathyroidi

sm• thyrotoxicosis, • insulin-dependent

diabetes mellitus, • acromegaly, • adrenal

insufficiency

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Drugs associated with increased risk of osteoporosis

- Glucocorticoids- Cycosporine- Cytotoxic drugs- Anticonvulsants- Excessive alcohol- Excessive thyroxine- Heparin- Lithium

WHO, Guidelines for Preclinical Evaluation and Clinical Trials in Osteoporosis, 1998.

T-Score

World Health Organization (WHO) Osteoporosis Guidelines

1.41.31.21.11.00.90.80.70.60.50.40.3

20 30 40 50 60 70 80Age

BM

D

Mean–2 SDConsider preventive interventionConsider therapeutic intervention

Mean Lumbar Spine BMD: Decades 3 to 9 of a Woman’s

Life

Bone Mineral Density Values

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OsteoporosisPATHOGENESIS1. Peak bone mass : about 20 years old - genetic, hormone, nutrition, life style2. Rate of bone loss : after age 30-45, bone

resorption (osteoclast)> formation (osteoblast) and become exaggerated after menopause

(50 years old)3. Bone remodeling : keep balance at 20-30

years old, after that become negative balance

Mechanism

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Osteoporosis Type 1 Type 2 Type

3 Postmenopausal Senile secondary

Age 55 -70 years 70-90 years all Sex(F/M) 6:1 2 :1 1:1Fx site vertebrae vertebrae vertebrae distal forearm hip hip distal

forearm

The threshold for Fx is reduced for osteoporotic bone

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Risk factor for osteoporosis fracture Potentially modifiable

1. Cigarette smoking2. Low body weight ( < 58 kg.)3. Estrogen deficiency : early menopause

(<45 years)4. Low calcium intake, high salt and protein

diet5. Alcoholism6. Inadequate physical activity7. Poor health

Lab InvestigationsCBC ESRSerum calcium (8.6 – 10.4 mg/dl)Serum phosphorus (3.00 – 4.5 mg/dl) Children 4-6 mg/dlSerum alkaline phosphatase (44 – 147 Iu/lit.) Children

1.5 -2.5 times more Liver function testsRenal function testsT3,T4, TSHPara thyroid hormonesVitamin D 25 (25 – 80 ng/ml)Protein electrophoresis (M band)Anti endomysial antibody (Coeliac disease)

Osteoporosis Treatment: Calcium and Vitamin DFewer than half adults take recommended

amountsHigher risk: malabsorption, renal disease,

liver diseaseCalcium and vit D supplementation shown to

decrease risk of hip fracture in older adults1000 mg/day standard; 1500 mg/day in

postmenopausal women/osteoporosisVitamin D (25 and 1,25): 400 IU day at least;

Frail older patients with limited sun exposure may need up to 800 IU/day

Osteoporosis Treatment: CalcitoninLikely not as effective as bisphosphonates

200 IU nasally/day (alternating nares)

Decrease pain with acute vertebral compression fracture

Osteoporosis Treatment: BisphosphonatesDecrease bone resorptionMultiple studies demonstrate decrease in

hip and vertebral fracturesAlendronate, risodronateIV: pamidronate, zolendronate (usually used

for hypercalcemia of malignancy, malignancy related fractures, and multiple myeloma related osteopenia)

Ibandronate (boniva): once/monthThose at highest risk of fracture (pre-

existing vertebral fractures) had greatest benefit with treatment

ESTIMATED DAILY CALCIUM INTAKES

RECOMMENDED DAILY INTAKE OF VITAMIN D

Milk equivalents containing 300 mg of calcium per serving

98% of a woman’s skeletal mass is acquired by age 20 Optimal strategies for building strong bones occurs during childhood and adolescence

A study of disease management in a rural healthcare population demonstrated that a preventive program was able to reduce hip fractures and save money.

1. A balanced diet rich in calcium and vitamin D

2. Weight-bearing and resistance-training exercises

3. A healthy lifestyle with no smoking or excessive alcohol intake

4. Talking to one’s healthcare professional about bone health

5. Bone density testing and medication when appropriate

Five Steps Toward Prevention

THANK U…Thank you