Metabolic Bone Disease

Differential Lab Results in Metabolic Bone Disease

Disease Calcium Phosphate ALP PTH VitD
Osteoporosis ↔ ↔ ↔ ↔ ↔
Osteomalacia ↓ ↓ ↑ ↔ ↓
Renal Osteodystrophy ↔/ ↑ ↑ ↑ v ↔
Paget's Disease of Bone ↔ ↔ ↑ ↔ ↔

Description
Osteoporosis is a reduction in overall bone mass and may be 1 o (age related) or 2o to other conditions or drugs. 18 %
of females (80 % of hip fractures are in women >50 YO) and 6 % of males >50 YO are affected. Trabeculae are lost in
women’s bones over time but in men it is mostly conserved.

In Osteomalacia, bone mass is conserved but mineral content is low (reverse of osteoporosis). This leads to rickets
when it occurs during bone growth while osteoporosis occurs after the fusion of the epiphyses.

Paget’s disease of the bone occurs when there is increased bone turnover associated with increased numbers of
osteoblasts and osteoclasts. This results in remodelling, bone enlargement and deformities. Rare <40 YO with 3 % of
>55 YO affected. It is more common in temperate climates and Anglo-Saxons.

Osteoporosis
Presentation
- Trabecular: Vertebral crush injury; Dowager’s hump
- Cortical: Long bone fractures; Femoral neck common
- NB: Femoral neck is biggest risk of death
Causes
- Important: RA; Corticosteroids; ↑↑ Levothyroxine
- Age: Bone mineral density decreases with age
- Lifestyle: Alcohol >4 units daily; BMI <19
- Systemic: Menopause; CKD; DM
- Activity: Prolonged immobility; Falls
- Drugs: SSRIs; Antiepileptics; PPIs; Thiazolinediones
Investigations
- Bloods: Ca2+; PO43-; ALP normal
- Bone densitometry: Bone mineral density (BMD)
- DEXA: <2.5 SD below young adult mean density
- NB: See table below for DEXA scoring
- T-Score: Based on bone mass of young population
- Z-Score: Age; Gender; Ethnic adjusted score
- X-Ray: Low sensitivity and specificity
- FRAX: 10 yr risk of fragility fracture
- NB: Assess all women ≥65 YO and ≥75 males
Management
- Lifestyle modifications
o ↓Risks: Smoking cessation; Alcohol reduction
o Diet: ↑ Calcium + VitD; ↑ BMI
o Home Aids: ↓ Fall risks
o Exercises: Weigh bearing; Balance
- Pharmacological
o Key: If Fragility fracture skip DEXA scan to treat
o Supplements: Calcium + VitD
o Bisphosphonate: Alendronate (CI: GFR<35;
PUD)
o Denosumab: RANKLi; Preferred if GFR <30
o Strontium Ranelate: Last line (CI: CVD)
o Raloxifene: Selective oestrogen receptor mod.
o HRT: Post-menopause (CI: Breast Ca; CVD)
o Teriparatide: Recombinant PTH (SE: Renal Ca)
o Calcitonin: ↓ Pain after vertebral fracture
- Steroid Therapy
o Risk: Significant if ≥75 mg for 3 months
o Key: Start bone protection immediately

Osteoporosis Risk Factors DEXA Bone Densiometruy WHO Criteria

Description T-Score Description
S Steroid use of >5 mg/d of Prednisolone >0 BMD is better than the reference
H Hyperthyroidism; Hyperparathyroidism; Hypercalciuria 0 → -1 BMD is in top 84 % (No evidence of osteoporosis)
A Alcohol + Tobacco use -1 → -2.5 Osteopenia (risk of later osteoporotic fracture)
T Thin (BMI <18.5) <-2.5 Osteoporosis (Repaet DEXA every 2 yrs)
T Testosterone deficient
E Early menopause
R Renal or Liver failure
E Erosive / Inflammatory bone disease
D Dietary Calcium deficiency/malabsorption; T1DM
Osteomalacia
Presentation
- Features: Bone pain; Fractures; Proximal myopathy
Causes
- VitD deficiency: Malabsorption; Poor diet; ↓ Sun
- Renal osteodystrophy: Calciferol deficiency
- Drug-induced: Anticonvulsants ↑ VitD breakdown
- VitD resistance: Inherited conditions (X-linked)
- Liver disease: ↓ Conversion of VitD  Calciferol
- Tumour: Hypophosphatemia + Hyperphosphaturia
- Inherited: X-Linked Hypophosphataemic rickets
Paget’s Disease of the Bone
Presentation
- ASx: Asymptomatic in 95 %
- Key: Older male; Bone pain; ↑ ALP
- Features: Deep bone pain in bones
- Bones: Pelvis; Skull; Spine; Femur; Tibia
- Untreated: Skull bossing; Tibia bowing
Causes
- Risks: ↑ Age; Male; Northern latitude; FHx
Investigations
- XR: Bow-Saber tibia; Bony enlargement; Hot-spots
- Bloods: ↔ Ca2+; ↔PO43-; ↑ ALP
- Other: P1NP; Serum CTx; Urine NTx; Urinalysis
Above: Bow-Saber
Tibia (classical)
Left: Skull thickening
Right: Hot-spots
shown on isotope
bone scan
Investigations
- Plasma: ↓ Ca2+; ↓ PO43-; ↑ ALP; ↑ PTH; ↓VitD
- X-Ray: Translucent bands (Looser’s zones)
Management
- Diet: Calcium + VitD3 supplements (Adcal)
- Liver disease: VitD2 (ergocalciferol); IM Calcitriol
- Renal disease: Alfacalcidol; Calcitriol
- NB: Risk of dangerous hypocalcaemia
- Inherited: Phosphate and Calcitriol supplements
- Monitor: Ca2+ weekly initially; Check during N&V
Management
- Basic: Analgesia
- Bisphosphonate: PO Risedronate; IV Zoledronate
Complications
- Bone: OA; Skull thickening; Hypercalcaemia
- SNHL: Nerve compression by bones (deafness)
- Cardiac: High-output CCF
- Onco: Osteosarcoma (<1 % cases >10 yrs post-Δ)