Osteoporosis

Intro

Osteoporosis is a systemic skeletal disease which results from low bone density and micro-architecture
deterioration of bone tissue which enhances bone fragility and increases the risk of fracture. It is
considered as the most common form of metabolic bone disease with 200 million people effected across
the world.

Cooper C, Campion G, Melton LJ, 3rd. Hip fractures in the elderly: a world-wide projection. Osteoporosis
Int. 1992;2(6):285-289.
The World Health Organization (WHO) operationally defines osteoporosis as a bone density that
falls below T score 2.5.

Epidemiology

Fractures caused by osteoporosis is one of the most common causes of disability in many regions of the
world. Every one out of two women and one in four men over 50 will have an osteoporosis-related
fracture in their life. There are cases for more than 1.5 million fractures due to osteoporosis annually,
including 300,000 hip fractures, 700,000 vertebral fractures, 250,000 wrist fractures and more than
300,000 fractures at other sites. In Caucasian women at age 50 years, the lifetime risk of fragile fracture
is 40% and in men 13% . Hip fractures have an overall mortality of 15-30%. So osteoporosis is a
detrimental disease which has numerous cases
worldwide.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781190/#R2

Osteoporosis and osteopenia

In the development of osteoporosis, there is a gradual progression of bone density loss. Osteopenia is
like a mid-stage when the bone density mass (BDM) is less than a healthy person but not as low as a
person with osteoporosis. Whether a person has osteopenia, osteoporosis or is healthy is determined by
T-score.

Pathophysiology

Peak bone mass

Peak bone mass is the maximum bone mass achieved by an individual at skeletal maturity, usually
between the age 25 to 35 years. After this, the bone mass decreases overtime so it is an important
factor in development of osteoporosis. As women achieve less peak bone mass than men, they are more
likely to develop osteoporosis.

There are many factors which determine the peak bone mass like genetic factors, nutritional status,
physical activity and gonadal status (low level of estrogen and testosterone)

Bone modelling and remodeling

Bone modelling and remodeling involves two cells osteoblast and osteoclast. Osteoblast are cells
involved in the formation and mineralization of bones, whereas osteoclasts are involved in the
breakdown and reabsorption of bones

Bone modeling is the process by which bones are shaped or reshaped by the actions of osteoblast and
osteoclasts. And bone remodeling is the reabsorption of old bones by osteoclasts and formation of new
bones by osteoblast. Normally, bones remodeling proceeds in cycles where osteoclasts adhere to bone
and subsequently remove it by acidification and proteolytic digestion. Afterwards osteoblasts invade the
area and start the forming new bone by secreting osteoid which is eventually mineralized. Parfitt AM. Osteonal
and hemi-osteonal remodeling: the spatial and temporal framework for signal traffic in adult human bone. J Cell Biochem 1994;55:273-286
In each year about 25% of trabecular bone is reabsorbed and replaced. Parfitt AM. The two-stage
concept of bone loss revisited. Triangle 1992;31:99-110
Osteoporosis results from the reduction of bone mass due to the imbalance between bone formation by
osteoblast and absorption by osteoclast during bone remodeling. This is influenced by several factors
like loss of gonadal function so decrease in estrogen,androgen and testosterone, vitamin D, parathyroid
hormone (PTH) and interleukines. Due to disruption of gonadal function, the ability of bone marrow to
form osteoblast precursors decrease resulting into decrease in the number of osteoblasts, this means
less bones will be formed than will be reabsorbed by osteoclasts decreasing bone density.
https://www.nejm.org/doi/full/10.1056/nejm199502023320506

Osteoporosis means "porous bones." 

Signs and symptoms

Osteoporosis is at time called “silent disease” because loss of bone mass takes years so does not show
any signs and symptoms in the early stage. But as the disease develops gradually, the following signs and
symptoms can be seen.

Easily fractured bone- even slight trauma could lead to fracture. Most common fractures associated with
osteoporosis are spine, hip and wrist.

Loss of height- tiny fractures in the vertebral column over time makes the spinal cord shorter and can
make an individual loose height up to 8 inches

Neck and lower backpain- pain is felt due to compression in the weakened vertebral column

Stopped posture- lack of bone density and breaking of several vertebrae results in abnormal curvature
of spine at the shoulder, this is mostly seen in older people and is called “widow’s hump”

Diagnosing osteoporosis

Although the bone density can be identified by x-ray and bone mass by radiography, the most preferred
method to diagnosis osteoporosis is “DEXA”

Dual energy x-ray absorptiometry (DEXA)/(DXA) – It determines the bone mineral density (BMD) by
measuring the amount of x-rays absorbed by bone tissue and correlates the data with bone mineral
density to find T score(comparison of a person's bone density with a healthy 30-year-old of the
same sex) and Z score (comparison of a person's bone density with that of an average person of
the same age and sex).
Risk factors

1. Advancing age – In elderly people, vitamin D insufficiency and low calcium absorption leads a
decrease in bone mass density (BDM) resulting in osteoporosis .
https://pubmed.ncbi.nlm.nih.gov/24903137/
2. Gender -Though osteoporosis effects both men and women ,it is four times common in women
than men after 50. In men, the BMD at the hip and bone mineral density at lumber is higher
than women .Also women start losing bone density at an early age and faster rate than men.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5380170/
Women tend to have smaller, thinner bones than me
3. Menopause – In women after menopause, oestrogen production from the ovaries decline. Due
to this, osteoclast’s activity increases which results in trabecular and endocortical bone
reabsorption increases leading to osteoporosis
The Ovariectomized Rat as a Model for Studying Alveolar Bone Loss in Postmenopausal Women
- Scientific Figure on ResearchGate. Available from:
https://www.researchgate.net/figure/Overview-of-how-osteoporosis-develops-after-
menopause-With-the-loss-of-endogenous_fig2_276127742 [accessed 12 Sep, 2020]

4. Ethnic group – the likelihood of Caucasian and Asian women to develop osteoporosis is
much more than women of other ethnic backgrounds
5. Medications – Many drugs like Corticosteroid and thyroid hormone replacement therapy disrupt
osteoblast and osteoclast activity and results in osteoporosis
6. Smoking and alcohol consumption-
7. Family history

Treatments

Some FDA approved pharmacologic dedications for osteoporosis includes –

 Bisphosphonates (alendronate, ibandronate, risedronate, and
zoledronic acid)
 Calcitonin
  Estrogen antagonist (raloxifene)
 Estrogens or hormone therapy
 Tissue-selective estrogen complex (conjugated
estrogens/bazedoxifene),
 Parathyroid hormone (teriparatide)

Prevention

 Calcium - Men aging 50-70 should consume calcium 1000mg /day, above 70 should consume
1200mg/day. Women aging 50 and older should consume calcium 1200mg/day.
 Vitamin D- Both men and women should intake vitamin D 800-1000IU/day
 Exercise It is also recommended to do muscle strengthening exercise and weight lifting exercise
to maintain posture,balance,strengthen muscles and bones and thud reduce risk of fractures.
Avoid central nervous system medications and antihypertensives.
 Smoking and alcohol- smoking and excessive alcohol intake should be avoided.

https://link.springer.com/article/10.1007/s00198-014-2794-2