Osteoporosis

Dr.S.Sethupathy

1
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?
 Age
 Estrogen deficiency
 Testosterone deficiency
 Family history/genetics
 Female sex
 Low calcium/vitamin D intake
 Poor exercise
 Smoking
 Alcohol
Who gets osteoporosis?
 Low body weight/anorexia
 Hyperthyroidism
 Hyperparathyroidism
 Prednisone use
 Liver and renal disease (think about vit d
synthesis)
 Low sun exposure
 Medications (antiepileptics, heparin)
 Malignancies (metastatic disease; multiple
myeloma can present as osteopenia!)
 Hemiplegia s/p CVA/ immobility
 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
Nutritional and Etiology
gastrointestinal disorders
•malnutrition,
•parenteral nutrition,
•malabsorption syndromes,
•gastrectomy,
• severe liver disease
(especially biliary cirrhosis),
•pernicious anemia.

Endocrine disorders
•Cushing's syndrome,
•hyperparathyroidism Hypogonadal states Hematologic
• thyrotoxicosis, •Turner syndrome, disorders/malignancy
•insulin-dependent •Klinefelter syndrome, •multiple myeloma,
diabetes mellitus, •Kallmann Syndrome, •lymphoma and
•acromegaly, •anorexia nervosa, leukemia,
•adrenal insufficiency •hypothalamic •mastocytosis,
amenorrhea, •hemophilia,
•hyperprolactinemia. •thalassemia.
Drugs associated with increased risk of
osteoporosis

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

7
 Bone Mineral Density Values
Mean Lumbar Spine BMD:
World Health Organization (WHO) Decades 3 to 9 of a Woman’s Life
Osteoporosis Guidelines
1.4 Mean
1.3
1.2 –2 SD
Consider preventive intervention

BMD
1.1
1.0 Consider therapeutic interventio
0.9
0.8
0.7
0.6
0.5
0.4
0.3
20 30 40 50 60 70 80
Age

T-Score

WHO, Guidelines for Preclinical Evaluation and Clinical Trials in Osteoporosis, 1998.
Osteoporosis
 PATHOGENESIS
 1. Peak bone mass : about 20 years old
- genetic, hormone, nutrition, life style
 2. 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

9
Mechanism
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 1:1
 Fx site vertebrae vertebrae vertebrae
distal forearm hip hip
distal forearm

 The threshold for Fx is reduced for osteoporotic

bone

11
Risk factor for osteoporosis fracture
 Potentially modifiable
1. Cigarette smoking
2. Low body weight ( < 58 kg.)
3. Estrogen deficiency : early menopause
(<45 years)
4. Low calcium intake, high salt and protein diet
5. Alcoholism
6. Inadequate physical activity
7. Poor health

12
Lab Investigations
CBC
ESR
Serum calcium (8.6 – 10.4 mg/dl)
Serum phosphorus (3.00 – 4.5 mg/dl) Children 4-6 mg/dl
Serum alkaline phosphatase (44 – 147 Iu/lit.) Children 1.5 -
2.5 times more
Liver function tests
Renal function tests
T3,T4, TSH
Para thyroid hormones
Vitamin D 25 (25 – 80 ng/ml)
Protein electrophoresis (M band)
Anti endomysial antibody (Coeliac disease)
Osteoporosis Treatment: Calcium and
Vitamin D
 Fewer than half adults take recommended
amounts
 Higher risk: malabsorption, renal disease, liver
disease
 Calcium and vit D supplementation shown to
decrease risk of hip fracture in older adults
 1000 mg/day standard; 1500 mg/day in
postmenopausal women/osteoporosis
 Vitamin 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: Calcitonin
 Likely not as effective as
bisphosphonates
 200 IU nasally/day (alternating nares)
 Decrease pain with acute vertebral
compression fracture
Osteoporosis Treatment: Bisphosphonates
 Decrease bone resorption
 Multiple studies demonstrate decrease in hip and
vertebral fractures
 Alendronate, risodronate
 IV: pamidronate, zolendronate (usually used for
hypercalcemia of malignancy, malignancy related
fractures, and multiple myeloma related
osteopenia)
 Ibandronate (boniva): once/month
 Those at highest risk of fracture (pre-existing
vertebral fractures) had greatest benefit with
treatment
RECOMMENDED DAILY INTAKE OF VITAMIN D
 Five Steps Toward Prevention
98% of a woman’s skeletal mass is acquired by age 20
Optimal strategies for building strong bones occurs during childhood and
adolescence
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
A study of disease management in
a rural healthcare population
demonstrated that a preventive
program was able to reduce hip
fractures and save money.
THANK U…
Thank you