Osteoporosis?

What Is Osteoporosis?

Osteoporosis means "porous bones." Our

bones are strongest at about age 30, then
begin to lose density. More than 10 million
Americans have osteoporosis, which is
significant bone loss that increases the risk of
fracture. About half of women 50 and older will
have an osteoporosis-related fracture in their
lifetime.

AAP

Frequency
Approximately 10 million people
have osteoporosis. Another 14-18
million have osteopenia (low bone
mass)

Approximately 1.5 million fractures per

year in the United States are attributed to
osteoporosis, and more than 37,000
people die from subsequent fracturerelated complications

Women vs. Men

Begin bone loss in
their 40s
Rapid loss of bone
mass for 5-10 years
after menopause
onset
Smaller bone cortices
and diameter from
growth phase,
especially during
puberty

Begin bone loss in

their 40s
Bone loss remains
linear and slow as
sex steroid
production
progressively
declines
Larger bone
cortices and
diameter from
growth phase

Other Risk Factors

Chronic glucocorticoid excess

Hyperthyroidism
Inappropriately high T4
replacement
Alcoholism
Prolonged immobilization
Gastrointestinal disorders
Hypercalciuria
Malignancies
Cigarette smoking

Medical Conditions Associated with

Increased Risk of Osteoporosis

COPD
Cushings syndrome
Eating disorders
Hyperparathyroidism
Hypophosphatasia
IBS
RA, other
autoimmune
connective tissue
disorders

Insulin dependent
diabetes
Multiple sclerosis
Multiple myeloma
Stroke (CVA)
Thyrotoxicosis
Vitamin D deficiency
Liver diseases

Drugs Associated with

Reduced Bone Mass

Aluminum
Anticonvulsants
Cytotoxic drugs
Glucocorticosteroids
(oral/high dose
inhaled)
Immunosuppresants
Gonadotropinreleasing hormone
(e.g. Lupron)

Lithium
Heparin (chronic use)
Supraphysiologic
thyroxine doses
Aromatase inhibitors
Depo-Provera

Anatomy The Skeletal

System
Functions of the Skeletal
System
Support against gravity
Leverage for muscle action movement
Protection of soft internal
organs
Blood cell production
Storage - calcium,
phosphorous, fat

The Skeletal System

The skeletal system includes:
Bones
Cartilages
Joints
Ligaments
Other connective tissues

General Shapes Of Bones

Long bones (e.g., humerus, femur)

Short bones (e.g., carpals, tarsals, patella
Flat bones (e.g., parietal bone, scapula, sternum)
Irregular bones (e.g., vertebrae, hip bones)

Structure of Typical Long Bone

Diaphysis - tubular shaft forming
the axis of long bones.
Composed of compact bone
Central medullary cavity
Contains bone marrow

Epiphysis expanded end of long

bones.
Composed mostly of spongy bone
Joint surface is covered with articular
(hyaline) cartilage
Epiphyseal lines separate the
diaphysis from the epiphyses

Metaphysis where epiphysis and

diaphysis meet

Bone Membranes
Periosteum

Provides anchoring points for

tendons and ligaments
Double-layered protective
membrane, supplied with
nerve fibers, blood, and
lymphatic vessels entering
the bone via nutrient
foramina.
Inner osteogenic layer is
composed of osteoblasts and
osteoclasts

Endosteum

Delicate CT membrane
covering internal surfaces of
bone
Covers trabeculae of spongy
bone
Lines canals in compact bone
Also contains both
osteoblasts and osteoclasts

Cells in Bone
Osteoprogenitor cells precursors to
osteoblasts
Osteocytes - mature bone cells between
lamellae
Osteoclasts - bone-destroying cells, break
down bone matrix for remodeling and release
of calcium
Source of acid, enzymes for osteolysis
Calcium homeostasis

Osteoblasts - bone-forming cells

Responsible for osteogenesis (new bone)
Source of collagen, calcium salts

Bone Remodeling/Homeostasis
Role of Remodeling in Support
RemodelingContinuous breakdown and
reforming of bone tissue
Shapes reflect applied loads
Mineral turnover enables adapting to new
stresses

What you dont use, you lose. The

stresses applied to bones during
exercise are essential to maintaining
bone strength and bone mass

Bone Remodeling
Bone is active tissue small changes in bone
architecture occur continuously 5 to 7% of bone
mass is recycled weekly spongy bone is replaced
every 3-4 years and compact bone approximately
every 10 years
Remodeling Units adjacent osteoblasts and
osteoclasts deposit and reabsorb bone at periosteal
and endosteal surfaces

Bone Remodeling
Bone Depostition
Occurs when bone is injured or extra strength is needed
Requires a healthy diet - protein, vitamins C, D, and A,
and minerals (calcium, phosphorus, magnesium,
manganese, etc.)

Bone Resorption
Accomplished by Osteoclasts (multinucleate phagocytic
cells)
Resorption involves osteoclast secretion of:
Lysosomal enzymes that digest organic matrix
HCl that converts calcium salts into soluble forms
Dissolved matrix is endocytosed and transcytosed into
the interstitial fluid the blood

Pathophysiology
Balance between bone resorption
and formation (remodeling)
Remodeling is in balance until about age
50

Osteoclasts resorb bone

Osteoblasts form bone
Estrogen inhibits osteoclastic bone
resorption
Peak bone mass is established by
age 20 for the hip and during the

Pathophysiology

Women have increased incidence of

osteoporosis compared to men due to:

Lower peak bone mass

Greater bone loss after menopause (10%
bone loss)

Men and non-white women have higher

peak bone mass than white women
Genetic factors 70-80% of peak bone
mass is genetically determined
Pregnancy and lactation cause transient
bone loss

Pathophysiology
Bone quality
Disruption of microarchitectural
elements of trabecular bone
Cortical thinning
Decrease in degree of mineralization

Bone Mineral Density Testing

So Who Do We Test?
Postmenopausal women older than 65 years
Postmenopausal women younger than 65 years who
have 1 or more risk factor
Postmenopausal women who present with fragility
fractures
Women who are considering therapy in which BMD
will affect that decision
Women who have been on hormone replacement
therapy (HRT) for prolonged periods
Men who experience fractures after minimal trauma
People with evidence of osteopenia on radiographs or
a disease known to place them at risk for osteoporosis

Lab Studies
Levels of serum calcium, phosphate,
and alkaline phosphatase are usually
normal in persons with primary
osteoporosis, although alkaline
phosphatase levels may be elevated
for several months after a fracture
It is important to also check thyroid
function, and testosterone levels in
men

BMD Imaging
BMD tests are usually done on bones
that are likely to break as a result of
osteoporosis like the lower spine and
hip
Can also be done on the wrist or heel
Devices that measure BMD include:
Quantitative computed tomography
Dual-energy x-ray absorptiometry
(DEXA)
Quantitative ultrasonography
Radiogrammetry

Quantitative Computed
Tomography
Quantitative computed tomography
measures BMD as a true volume density in
g/cm3, which is not influenced by bone
size.
This technique can be used for both adults
and children.
Disadvantages in that (1) it only
determines bone density at the spine, (2)
osteophytes can interfere with
measurement, and (3) it is associated with
significant radiation exposure and high
cost

DEXA
Dual-energy x-ray absorptiometry requires less
radiation, is less expensive, and has better
reproducibility than quantitative computed
tomography
Can also measure bone density at the spine and
the hip. It has become the standard method for
determining bone density.
This method can be used in both adults and
children
Confounding factors in DEXA results
interpretation (falsely high bone density) include
spinal fractures, osteophytosis, and extraspinal
(eg, vascular) calcification
Peripheral DEXA can be used to measure BMD in
the wrist

Quantitative
Ultrasonography
Quantitative ultrasonography of the
calcaneus can be used for general
screening
However, this is not as accurate as
other methods and thus is less useful
in following response to treatment
Its advantages include low cost,
portability, and lack of ionizing
radiation

Radiogrammetry
Radiogrammetry, used to measure
cortical dimensions, is usually
performed on the hand, specifically
the second metacarpal
It is useful in assessing BMD in
children and is the simplest and least
expensive method
Disadvantages are that it is not as
precise as DEXA and, therefore, is
less sensitive for detecting changes
over time

What Are The Results?

Results are reported as two values, T and
Z scores
T scores are the number of standard
deviations above or below what is
normally expected in a healthy young
adult of the same sex
Z score is the number of standard
deviations above or below what is
normally expected for someone of the
same age, sex, weight, and ethinic origin

T Score
Above -1 indicates the bone density
is normal
Between -1 and -2.5 indicates bone
density is below normal, or
osteopenia
Below -2.5 indicates osteoporosis

DEXA Images

BMD Score Report

Z Score
The Z score is help ful because it
may suggest that the patient may
have a secondary form of
osteoporosis unrelated to normal
aging which is causing decreased
BMD
A score less than -1.5 should make
you investigate the cause of
decreased BMD

Another Report Card

For example, if the T-score is -2.0, the BMD is
lower than average by two standard deviations. If
the Z-score is -0.5, your bone density is less than
the norm for people your age by one-half of a
standard deviation

QCT

QCT
QCT isolates metabolically active
trabecular bone for greater anatomic
accuracy than other methods
A series of axial scans are taken with
the patient lying on a calibration
phantom

Other Tests
As mentioned earlier, ultrasound and
radiogrammetry can be used as well
These are not as accurate in
determining BMD loss but have
advantages like less radiation,
smaller equipment, and they
measure BMD using smaller bones

Treatment
Universal Recommendations :
Adequate intake of calcium, vitamin D
Weight-bearing and muscle-strengthening exercises
to reduce risk of falls/fracture
Provide strategies for fall prevention
Avoidance of tobacco use/excessive alcohol use
Talk to your provider about bone health
Have a bone density test and take medication when
appropriate

Adequate Intake of Calcium/Vitamin D

Adequate intakes of dietary calcium and
vitamin D, including supplements if
necessary
Elemental calcium per day (> 50 YOA) = at
least 1200 -1500 mg
Vitamin D3 per day (> 50 YOA) = 800 -1000
international units (IU)

Vitamin D3 (cholecalciferol) plays major

role in Ca absorption
Controlled clinical trials have
demonstrated the combination reduces
fracture risk

Calcium/D Product
Selection
Product (%
elemental Ca)

Calcium carbonate
(40)
-Tums Ultra
-Caltrate 600 Plus
-Oscal Plus D
-Viactiv Chews
Calcium citrate (24)
-Citracal Plus D
- Citracal Petites
with VitD
Vitamin D
-Multivitamin (D3)
-Vitamin D

Element
al
Calcium
(mg)

400
600
500
500

Vitamin
D
(units)

200
125
100

315
200

200
200

120-450

400
100400

Comments

Requires acidic environment for

dissolution and disintegration. Best to
take with meals. Greater risk for
constipation with carbonate form.

Take without regard to meals. Serving

size usually equals 2 capsules so label
can be misleading to patients.

Vitamin D and Fall Risk

In addition to its effect on BMD, may contribute to reduction

in fracture risk
Improved muscle function
Reduction in risk for falls

Meta-analyses of 5 clinical trials (> 60 YOA) showed

significant reduction in risk for falling in those taking vitamin
D plus calcium versus those taking placebo

Vitamin D deficiency prevalent in older adult population

Inadequate sun exposure, use of sunscreen

Homebound, institutionalized
Northern latitudes

Maintain 25-hydroxyvitamin D3 at least > 40 ng/mL

Treatment: 50,000 IU vitD weekly x 6-8 weeks, then
assess need for chronic monthly therapy

Regular Weight-Bearing
Exercise
Defined as those in which bones and
muscles work against gravity as feet and
legs bear the bodys weight
Include walking, jogging, Tai-Chi, stair
climbing, dancing, tennis, yoga
Improve agility, strength, balance
May increase bone density modestly,
reduce fall risk, enhance muscle strength,
improve balance

Avoidance of Tobacco and Alcohol

Tobacco products detrimental to
skeleton, overall health
NOF strongly encourages tobacco
cessation programs as osteoporosis
intervention
Excessive alcohol intake also
detrimental to bone health and
requires treatment

Who Should Be Treated?

NOF Recommendations 2008

Initiate therapy to reduce fractures in

postmenopausal women/men > 50
with:
1.
2.
3.

BMD T-scores < -2.5 at hip or spine

Prior vertebral or hip fracture
Low bone mass (T-scores -1.0 to -2.5 at
hip or spine) when:
10-year probability of hip fracture is > 3%
10-year probability of major osteoporosisrelated fracture is > 20%
Based on US-adapted WHO algorithm
www.nof.org

FDA-Approved Drugs for Osteoporosis

Bisphosphonates

Alendronate,
Alendronate plus D
(Fosamax, Fosamax
Plus D)
Risedronate,
Risedronate with
Calcium (Actonel)
Ibandronate (Boniva)

Selective Estrogen
Receptor Modulators
(SERMs)
Raloxifene (Evista)

Calcitonin (Miacalcin ,
Fortical , Calcimar )

Parathyroid Hormone
[PTH (1-34),
teriparatide]
Forteo

Estrogen/Hormone
Therapy (ET/HT)

Premarin, Estrace,
Prempro

Daftar Pustaka
Varnada Karriem-Norwood, MD. A Visual Guide to
Osteoporosis.
Diunduh
dari:
http://www.webmd.com/osteoporosis/ss/slideshow-osteop
orosis-overview#
Diakses 7 Januari 2014.
Bauer, DC. Use of statins and fracture: results of 4
prospective studies and cumulative meta-analysis of
observational studies and controlled trials. Arch Intern
Med. 2004 Jan.
Dempster DW, et al. J Bone Miner Res. 1986:1:15-21;
Reprinted with permission from the American Society of
Bone and Mineral Research.
AACE Guidelines for Diag and Treatment of Osteoporosis 2010