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OSTEOPOROSIS

Blondina Marpaung
Rheumatology Division
Internal Department
Medical Faculty USU - Medan

EPIDEMIOLOGY
Osteoporosis is a major public health problem, and
postmenopausal osteoporosis constitutes as a major part
of the problem.
Claus Christiansen, Am J Med 1993

Hip fractures will increase sharply in the next half


century, especially in Asia, making osteoporosis a truly
global issue.
WHO 1998

Introduction
Osteoporosis is a disease characterized
by low bone mass and microarchitectural
deterioration of bone tissue, leading to
enhance bone fragility and a consequent
increase in fracture risk
(WHO)

Osteoporosis is a skeletal disorders


compromised bone strength,
predisposing in an increase risk
of fracture

Rigg and Nelson divided into :


A/. Primary osteoporosis
1. Post menopause osteoporosis
2. Senile osteoporosis
B/. Secondary osteoporosis
Osteoporosis due to other condition
of disease such as metabolic,
endocrine or malignancy

Post menopausal osteoporosis


Most common in woman 15 20 year after menopause
Mostly affects trabecular bone, increasing patient
susceptibility to vertebral compression fractures,
distal radial fractures and intertrochanteric fractures.
Esterogen deficiency plays a primary role

Senile Osteoporosis
Occurs

in men and women over the age of 70


years with female to male ratio of 2:1
It affects : cortical and trabecular bone
equally, predisposing patient to multiple
wedges vertebral and femoral neck fractures
Aging and long-term calcium deficiency is
more important.

Primary osteoporosis mostly are old and


elderly people complaining of mild
backache but may also a sudden pain
with only a mild injury due to a
compression fractures of the vertebrae.

Before it reaches the threshold of fractures,


usually the height of patient reduces beside
deformity (kyphotic deformity)

It is a silent disease, meaning there is


no significant signs and symptoms
caused by osteoporosis

Etiology :
General factor predictive of osteoporosis :
1. Peak bone mass at maturity :

General / familial
Nutritional
Physical (activity status, exercise, etc)
Life style (alcohol, cigarettes, caffeine)
Medical (chronic disease, hypogonadal states, etc
Iatrogenic (corticosteroid, anticonvulsant, etc)
Orthopaedics Study Guide, Metabolic Bone Disease, 1999, p.885-889

Bone Mass
Development

Bone Mass

Peak Bone Mass

Bone Loss

male

Menopause

female

20

40

age

Age (year)

60

80

2. Post menopausal bone loss


Accelerated trabecular bone loss for 3
to 10 years post menopausal
Due to increased bone resorption
secondary to estrogen loss
Loss of normally 1 to 2% per year to
a maximum of 10%
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

3. Age-related (involutionall) bone loss


Starts at age 35 40 years in both sexes,
continues for 30 to 40 years
Subtle uncoupling of rates of bone formation
and resorption
Both cortical and trabecular bone affected
Loss normally less than 0.5% per year to a
maximum of 20 %
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

4. Risk factors
Genetic, life style, Medical, Iatrogenic
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

Risk factors for bone


loss :
1. Genetic

- Female sex
- Caucasian / Asian ethnicity
- Family history of osteoporosis

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

2. Life Style

- Low calcium intake


- Excessive alcohol use
- Cigarette smoking
- Excessive caffeine use
- Extreme or insufficient athlecity
- Excessive acid ash diet (high protein /
soft drink intakes)

Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

3. Medical :
- Early menopause
- Gonadal hormone deficiency
states
- Eating disorders
- Chronic liver / kidney disease
- Malabsorption syndrome
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

4. Iatrogenic

- Corticosteroids
- Excessive thyroid hormone
- Chronic heparin therapy
- Radiotherapy to skeleton
- Long-term anticonvulsants
- Loop diuretics
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

Bone is the most dynamic tissue.


Metabolism of catabolism and anabolism
as the activity of osteoclast and osteoblast
as a process of bone remodeling or
bone turn over

Degeneration occurs as an aging process


where the activity of osteoclast is not able
to compensate by the activity of osteoblast.
As a result bone mineral density decrease

The main problem of osteoporosis


lies in the effectiveness of interventionprevention and treatment

Osteoporosis is preventable if prevention

starts during the childhood and adolescence


when bone reaches maturity at the end
of 3rd decade to achieve maximum
Peak Bone Mass

After the 3rd decade all organ include


skeletal / bone will degenerate, the speed
of degeneration, differs for different
organ.
In general organ will loose function
1% every year (the rule of 1% of Andreas
and Tobin)

Diagnosis should include differential diagnosis of


primary and secondary osteoporosis by :
o Taking a good history
o Physical examination
o Laboratory examination
o Imaging examination

DIAGNOSIS
History :
o ras, sex and age
o health status
o life style (alcohol, smoking)
o physical activity (sports)
o history of previous disease including administration of
drugs, previous fracture.

Physical Examination :
Body weight and height (BMI)
Extremities and spine including :
deformity, MMT and ROM

Laboratory findings :
o blood serum
o hormone
o Urine

LABORATORY FINDINGS :
Routine:
- Serum :
- Complete blood counts
- Electrolytes, creatinine, blood urea, nitrogen calcium
- Phosphorus, protein, albumin, alkaline phosphatase,
liver enzyme
- Protein electrophoresis
- Thyroid function tests
- Testoterone (men only)
- 24 hours urine :
- calcium
- Pyridinium cross-links

LABORATORY FINDINGS :
Spesial :
- Serum:
- 25 hydroxyvitamin D3
- 1,25 hydroxyvitamin D3
- intact parathyroid hormone
- osteocalcium (bone Gla protein)
- Urine :
- Immunoelectrophoresis
- Bence-Jones protein

IMAGING :
Radiology : plain X-ray
(especially the spine, hip and wirst)
The spine

- the ballooning disc


- deformity of vertebral body
(wedge, fish tail)

The Hip

- Singh Index

The Wirst

- Porotic / thinning cortex

The general diagnostic categories


established in woven : (WHO working group
Normal

: Bone Mass Density (BMD)or


Bone Mineral Content (BMC)
-1 SD from T Score of the young
adult reference mean
Osteopenia : BMD or BMC 1 SD to 2.5 SD
Osteoporosis : BMD or BMC 2.5 SD

(severe osteoporosis when there is followed a fractur

Prevention and Treatment


T-score

Fracture risk

Teatment

> +1

very low

no treatment
densitometry with indication

-1 s/d 0

low

no treatment
densitometry after 5 years

- 1 s/d +1

low

no treatment
densitometry after 2 years

-1s/d -2,5

midle

prevention
densitometry after 1 years

< - 2,5
no fracture

high

osteoporosis treatment
continue prevention
densitometry after 1 years

< - 2,5
With fracture

very high

osteoporosis treatment
continue prevention
surgery with indication
densitometry after within

Prevention
Aging process is a natural process of a person
getting old
3 steps of osteoporosis prevention :
I. Up to the end of 3rd decade
where Peak Bone Mass should be
achieved
II. After the 3rd decade up to menopause /
Andropause
III. Senile, prevent from minor injury /
accident

Goal of Osteoporosis Prevention


Optimising skeletal development
Nutrition
Physical activity
Life style changes
Minimize medical / iatrogenic factors
Minimize postmenopausal bone loss
Early identification of patients at risk
Reduced risk factors
Hormone replacement therapy (HRT)
Other agents pre-emptively if HRT
contraindicated
raloxifene, alendronate
Minimize age-related bone loss
Identification of patients at risk
Reduce risk factors
Full prevention and exercise program (physical
therapy) Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889

1st Prevention :

Good nutrition

Life style and physical exercise

To achieve maximum Peak Bone Mass

2nd Prevention

Early diagnose of osteoporosis


st
The same prevention as 1 prevention
In female patient after menopause with HRT
Prevention of the use of medication
consist steroid etc

3rd Prevention
Prevent from accident
(minor injury could cause fracture)
Care giver especially after fracture
Operative intervention and bracing

Treatment
Nowadays there is a lot of medication
For osteoporosis such as :
- calcium and vitamin D
- calcitriol
- calcitonin
- bisphosphonate : generation : I III
such as (clorodronate, alendronate, and
risedronate (actonel))
- hormone : - anabolic
- sex hormone
- SEMs (Selective Modulator)
- SERM (Selective Estrogen Reseptor
Modulator : Raloxifene
(analogue of tamosifene)
SURGERY

Calcium

: 1500 mg / day

Vitamin D : 500 mg / day


Calcitonin (myacalcic : Nasal spray: 200 mg / daily)

HRT

: establish approach for osteoporosis prevention


and treatment.
But what after WHI report ????

SERM : Raloxifene : Evista : 60 mg/daily


- the goal is to increase bone benefits and decrease
deletterious affects on breast and endometrim.
- decrease breast cancer : 76 %
- 60 % women, 2 years : BMD increase 1-2 %

Dr. C. Deeply

CALSIUM DAN VITAMIN D RICH DIET


4 SEHAT 5 SEMPURNA
CALSIUM NEEDED
Child
Teen ager
Adult
Pregnant
lactation
Premenopause
Intra menopause
Post menopause

400 700
1000 1500
750 1000
1500
2000
800 1000
1000 1200
1200 1500

mg
mg
mg
mg
mg
mg
mg
mg

/
/
/
/
/
/
/
/

day
day
day
day
day
day
day
day

100 g

40 g
100 g

Emping

1 gelas

20 gr

Food ingredient

Teri nasi
Kepiting

consist of 1000 mg Kalsium


210 mg
Kerang
133 mg
Dencis kaleng
200 mg
Kuning telur ayam
147 mg
Tempe
129 mg
Tahu
124 mg
100 mg
Bayam merah
347 mg
Kacang panjang
347 mg
Daun singkong
165 mg
Susu kental manis
275 mg
Susu segar
380 mg
susu krim penuh
290 mg
Susu non fat
480 mg
yurgort
200 mg
keju
100 mg

PREPARAT KALSIUM YANG TERSEDIA DI PASARAN


No.Type of Calsium
1. Calcium Carbonate

2. Calcium Lactate

3. Calcium Phosphate

Note :

Brand name
Ca-C 100 Sandoz
Calsan
Caxon-F
Calsium Sandoz
Epocaldi
Ca-C 1000 Sandoz
Calcidin
Calsium Sandoz
Calcidin
Calcalcin

Calcium carbonate mengandung 40 % kalsium


Calcium lactate
mengandung 13 % kalsium

Calsium(mg)
327
1250
250
300
400
1000
100
2940
200
800